Thursday, December 18, 2014

Time to update the AOTA Position Paper on Nondiscrimination and Inclusion

Politically controversial conversations continue to spew from the social media accounts of AOTA leaders.  These conversations represent perspectives that are not reflective of the broad membership and are highly partisan.  The steady stream of ideological thinking is concerning because it represents a pattern where some leaders don't know how to separate their personal political inclinations from the mission of a diverse professional association.

We often associate topics of diversity and nondiscrimination and inclusion in racial or ethnic or religious perspectives.  However, in what is supposed to be a politically neutral environment like a professional association, we can also consider the negative impact that is caused when leadership adopts a partisan and biased political agenda.

This is not a new problem with the American Occupational Therapy Association.  The inclusion of Social Justice in the Code of Ethics was the first major foray of leaders into political partisanship.  What makes this situation challenging is that many who supported Social Justice in the AOTA Code of Ethics refused to acknowledge that Social Justice itself was even a political concept!  Those refusals to accept the political realities of the term are well documented.  

This week we have a blog post that supports of the role of occupational therapy to assist in data mining to improve population health.  That AOTA leader writes: "As occupational therapy practitioners we can contribute to understanding the needs of individuals, communities and populations, help to design interventions at all levels and help interpret big data to translate it to meeting the needs of individuals."

On its surface, the objective here is hardly arguable - who would NOT want to help design multi-level interventions that prevent disease or illness or dysfunction?   That is a very noble goal.

However, consider what needs to happen in order to achieve that.  The Carolinas Health Care System has been using EHR data to predict patient health and medical system use.  Buried deep in their own admission of data mining is this statement: "Earlier this year, Carolinas HealthCare System also joined the Data Alliance Collaborative; a first-of-its-kind initiative aimed at improving population health on a national scale through data analytics and shared business intelligence."

Well what does that mean exactly?  Watch this brief video of Bloomberg Health Reporter Shannon Pettypiece discussing the problem:



For a more detailed discussion, read Pettypiece's original article entitled "Hospitals are mining patient's credit card data to predict who will get sick.

It is true that a very large healthcare system in the United States is playing around the edges of this extremely controversial marriage between 'Big Data' and our health - and that is unfortunate.  That does not mean that occupational therapists want to or even should jump on this kind of very controversial bandwagon that infringes on personal liberties and is associated with a political ideology of increasing State control.  

In another incident, last week it was disappointing to see one of our AOTA leaders re-tweet a statement that was overtly political and that was not reflective of the broad diversity of political opinion that AOTA members hold.  That tweet was:

"The opposite of disease is not health or wellness. The opposite of disease is justice."

That AOTA leader has since deleted the re-tweet that was sent out after I responded to it and called it 'Newspeak.'

What I wish that AOTA leader realized, and what is important for members to know, is that this statement that was re-tweeted was made by a presenter at the Institute for Healthcare Improvement's (IHI) annual conference.   The IHI is a group that purports to promote healthcare improvement but they are also known to be heavily populated by very partisan thinkers.  The group admits the following: "As we entered our third decade, we recognized a new need for health care as a complete social, geopolitical enterprise. To accelerate the path to the health and care we need, IHI created the Triple Aim, a framework for optimizing health system performance by simultaneously focusing on the health of a population, the experience of care for individuals within that population, and the per capita cost of providing that care."  www.ihi.org/.../History.aspx

In simple terms, they promote a socialized model of health care.  Their founder has heaped praise on the British model.

Dr. Berwick (founder and former CEO) was an Obama appointee as head of Centers for Medicare and Medicaid. www.whitehouse.gov/.../president-obama-nominates-dr-donald-berwick-administrator-centers-medicare-and-medi

What the White House release does not tell you is that he had to be appointed through a recess appointment and that he ended up resigning because there was no way he would ever be confirmed.  www.nytimes.com/.../dr-donald-m-berwick-resigns-as-head-of-medicare-and-medicaid.html

Dr. Berwick is (in)famous for quotes including (easy reference on Wikipedia page en.wikipedia.org/.../Donald_Berwick):

1. "The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open."

2. "Any health care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional."
These are Marxist statements.  Berwick has attempted to dance around these statements and claims that people take him out of context but it is difficult to interpret these statements in any way other than what they plainly say.

The point here is that the IHI is a liberal think-tank that is eyeball deep in its connections to a partisan agenda to socialize our healthcare system.  It is not shocking at all when statements get tweeted out of that conference like "The opposite of disease is not health or wellness. The opposite of disease is justice."

It is very difficult to understand how there can be any equivocation about the politicization of our profession when our leaders re-Tweet this kind of partisan nonsense.

I ask all of our leadership to respect the political diversity of our profession and to keep politics out of our association.  I also ask the leadership to steer clear of other politically controversial initiatives like 'Big Data' mining.

At this point in time it is becoming evident that some AOTA leaders are either tone deaf or they simply don't care and they are willfully infusing controversial politics into the profession.  We have reached a point where it is now necessary to make a specific procedural request that our profession avoids partisan ideologies and toxic political agendas that alienate members who do not share those political philosophies.

Wednesday, December 17, 2014

Why there is not much more to say about the NYS Early Intervention Program

I got an interesting question in email today so I decided I would answer it publicly.  The email asked:

You used to write a lot about early intervention, but there hasn't been much on that topic lately.  Providers are still struggling, there are provider shortages in some areas, lots of people lost their businesses and either went into agencies or gave up on early intervention.  Are you still working in this area and will you still be writing about how we are struggling with early intervention?

Here is my answer:

The reason why I don't write about early intervention as much anymore is because everything that I predicted about the municipal takeover of the system has come to fruition.  There just isn't anything left to say about it, and now the program will limp along in a reduced capacity just as planned.  The transition to the State Fiscal Agent system was intended to destroy the program as it was previously designed and that objective has been met.  In place of the previous system the new system is served only by larger agencies that have better capacity to withstand the new inefficiencies because those agencies operate on larger volume and have other revenue streams.

The impact on families is significant, particularly for those areas that have had intermittent provider shortages.  In insurance lingo, constricted provider pools are known as 'temporary revenue enhancement functions.'  In family lingo, constricted provider pools are known as "Oh my goodness, what will my child do without their physical therapy sessions???"

Families have been conditioned in our new welfare state to accept what is given, even when what is given is not particularly functional.  This facilitates a two-tiered care system.  The lower tier is populated by people who are conditioned to accept whatever service they can get for free out of a municipality.  The higher tier is populated by people who know that the lower tier solution is only for those families who don't have other options or other resources - and they go and find private solutions.

This was all predicted.

Many MDs in the community who have figured out that it is simply more efficient to refer their patients to me privately and for me to bill insurance directly.  Those families are very happy with that option because they don't have to wade through the bureaucracy of the EI system and they know in advance who they are getting as a service provider.  Unfortunately, many families don't have that option.

So there just is not much to say.  The new system is unwieldy and ineffective and bureaucratically deceptive.  The State Fiscal Agent reports the following statistics for 2014, through the third quarter:

Claims submitted to insurance: $67, 938, 442
Claims paid by insurance: $8, 958, 843
Percent reimbursed: 15%

It must be that new math that I don't understand, but whatever.

Imagine if any private health care practitioner could only collect such a low rate on claims?  And guess who gets to pay for every dollar that this inefficient behemoth can't collect?

This is the pathetic and expensive Early Intervention Program that NY taxpayers are paying for.

Tuesday, December 02, 2014

The incompatibility of population-based public health models with the occupational therapy profession

The following Twitter conversation underscores the problems with use of a population health model in an occupational therapy context:


Framing a conversation about the need for older drivers to consider their abilities underneath a context of population statistics is in direct conflict with the profession's Core Value of respect for patient autonomy and individuality.

Although it may be true that there are descriptive statistics about driving safety, numbers of accidents, and other factors associated with elderly drivers, when we lead our conversations with talk about the broad population we are adopting a potentially ageist stance that restricts the freedom of many drivers who are not falling within those normative ranges.

This is the problem with use of a population health model for meeting the needs of individuals.  To describe this problem within a general systems theory framework, consider the following chart:


Within this traditional framework of intervention, the correct focus and domain of concern is centered around the individual person.  Due attention is given to levels above and below the person because of their contextual relevance, but the focus of concern is the person.

Now consider a shift toward a population health model, where the focus and domain of concern is centered around the community:


In this type of public health framework the ability to focus attention on the individual and their abilities and their autonomous choices is lost.  This is why people state that public health models are inherently paternalistic and are not considerate of the needs of individual people.

The ethics required for supporting action in each scenario are radically different, and you can't populate a health care profession with a competing set of ethics where one focus respects patient autonomy and the other focus promotes paternalism and concern for a 'common good' that might not respect individuals.

Population health models are focused on broad community needs and frame concerns in broad population statistics.  It is philosophically incorrect to lead into an issue citing population statistics and then follow up with statements that individual assessments need to be considered.

What is the message?  Based on current life expectancies in the US, do people hand in their car keys when they are 70 because our population statistics indicate that this is when the elderly population statistically begins demonstrating concerns?  Will occupational therapists become the gatekeepers for driving, based on their assessment of abilities?  Will they solve those problems by paternalistic messaging that once you are 70 you are automatically placed in that high risk pool?

Occupational therapy was a profession that was established to help individual people when they had illness, disease, or disability so that they could productively engage in their lives.  Now there are some therapists who are trying to be gatekeepers to population health, wielding statistics and clipboards to make broad recommendations about when people need to start giving up their freedoms and autonomy.

 It is a disturbing philosophical turn that breaks our social contract with the people who would come to us for help.