Identifying Dilemmas

Leading Difficult Discussions

Building Collaboratives

Conveying Public Views

Identifying Dilemmas
Problems in healthcare practice or policy often surface gradually.  Though healthcare leaders must address these conundrums, the general public is often the last to be asked its opinion on how society should tackle difficult issues that ultimately affect everyone. A core aspect of CHCD’s work is identifying those healthcare dilemmas where 1) there are no easy answers and 2) the public’s voice has not been heard.

CHCD looked closely at what was behind this and found many years of debate and disagreement about medical care that doctors provide to patients near the end of life.  This subject, “medical futility,” was a major ethical and economic problem for hospitals, physicians and families.   Realizing that this was also a problem in the Sacramento region, CHCD identified the key questions that needed to be asked of the public: How should decisions be made for patients who are dying or irreversibly ill?  How can conflicts be avoided?  This topic was the genesis for CHCD’s first multi-year ECHO Project.

Examples of other healthcare dilemmas that CHCD identified:

• Can a medical treatment be too costly for the benefit it brings to patients?
• What aspects of healthcare coverage are most important to employees if their employers are struggling to pay for health insurance?
• California faced major statewide cuts greatly impacting the Medi-Cal budget.  Everyone had an opinion, but what did Medi-Cal beneficiaries think?
• Policy leaders started talking about ‘basic’ healthcare benefits but no one defined what that meant. What did community members think should comprise a basic benefits package?

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Leading Difficult Discussions  
Once a dilemma has been identified, CHCD then develops processes for engaging the public in ways that bring informed civic discourse. There is no more powerful process than group deliberation and the give-and-take of various viewpoints.  The key to tackling a complex subject is finding the structure for a group discussion that will challenge, inform and elicit the core values expressed through discussions, debates and decisions.

For example, in the case of the ECHO project, CHCD developed three scenarios, illustrating the types of cases that are common to concerns about using life-sustaining treatment:

• A very premature baby was likely to die soon; the parents wanted the child to live though the doctors didn’t think that was best.
• A man had advanced Alzheimer’s Disease; the doctor wanted to continue life-extending treatment but the wife wasn’t sure.
• A women was near death but had asked that “everything be done;” seeing the state she was in, her husband was conflicted.

Ninety two-hour discussion groups were held in the Sacramento region, involving more than 900 residents.  What participants thought was important – who makes these decisions, how they should be made, how to avoid and resolve conflicts – was critical to developing the ECHO hospital recommendations.

Examples of other CHCD group processes:

• Interactive program to expose healthcare and policy leaders to the challenges of designing lower-cost health insurance.
• Statewide discussion groups with diverse community members on paying for costly treatments: is the gain worth the expense?
• Prepared a guide to help communities conduct group discussions on advance care planning.

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Building Collaboratives
Improving healthcare policy and practice starts and ends with collaboration and cooperation among diverse stakeholders. While the public must be at the table, so must other key players.  CHCD provides a leadership role in the Sacramento region and assists other regions – in California and other states – in ways of working together to benefit individuals and the community at large.  

Examples of community collaboration:

• Brought together clinical leadership from 15 hospitals to forge recommendations for life-sustaining treatment and palliative care.
• Convened state leaders in long-term care to craft a consensus document for care at the end of life for nursing home residents.
• Worked with Latino and Chinese leaders to develop advance care planning programs that serve their specific communities.
• Consulted with state leaders in Hawaii, Oklahoma, Ohio and Montana to involve their constituents in a healthcare prioritization process. 

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Conveying Public Views
‘Policymakers’ range from local hospital administrators and medical directors to health plan executives, county supervisors, state regulators, legislators and national leaders – thought-leaders as well as elected representatives. Conveying the public’s views in a variety of forums is an essential aspect of helping to bring constructive change.

Examples of ways that CHCD communicates with policymakers:

• Presented the perspectives of Medi-Cal beneficiaries at a briefing for California state leaders regarding changes in healthcare coverage.
• Presented the public’s views on cost-effectiveness to an expert panel sponsored by the U.S. Agency of Health Care Research and Quality (AHRQ).
• Publishes articles in Health Affairs, the national health policy journal, on the views and values of the public when resources are limited.
• Makes presentations at state and national conferences on Californians’ decisions about societal priorities.

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