Check your patron

Reciprocity.  It is customary in ethics to discuss the connection between purpose and values in terms of reciprocity.  The body of knowledge in any discipline - that is, the reflective concepts and the action of technology - is derived from its reciprocal relationship to the purpose of its services... Searching for patronage and constructing a new support system is a dangerous venture for any discipline.

...The shift to a client system represents, perhaps, a desperate strategy to survive under the awesome pressure of the self-interest of medicine.  - Reilly, (1984).

Last year I noted that an article published in the American Journal of Occupational Therapy furthers the politicization of the professional association by endorsing very partisan approaches to health care (aka 'Triple Aim' model).  The chronic difficulty with labeling something as 'partisan' is that there will always be that segment of the population that agrees with that approach and does not see it as 'partisan.'  I take the risk in labeling anyway and hope to show why there is reason to pause and carefully consider these approaches.

The authors of the article (Leland et.al., 2015) align the concept of 'value' with the IHI 'Triple Aim' that includes "improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." (Berwick, Nolan, and Whittington, 2008).

Occupational therapists should ask themselves and their professional association when it became their duty to control for the amount of cost that the government is incurring in health care.  Responsible therapists should always be economically prudent and should be properly cognizant of the costs associated with their services, but is it the job of occupational therapists to meet the economic goals of a governmental patron?

If the purpose of occupational therapy is overtly stated as 'reducing the per capita costs of care for populations' then how does that position us ethically when it comes time to deliver care?

Simply put, the government defines 'value' in terms of dollars spent.  Most occupational therapists define 'value' in terms of people helped.  Those are not mutually exclusive objectives, but aligning your professional purpose with cost-saving methodologies changes your entire ethical system.

Where can we find 'value' propositions where occupational therapists have unexpectedly aligned themselves with government patrons?  Look at the slogan from the College of Occupational Therapists in the UK:

The important consideration here is that most occupational therapy services in the UK are delivered within the context of a single-payor government-run health care system.  That is not the case (yet) in the United States, although it is the particular objective of many partisans who are interested in fully socializing our health care payment system.

Who, exactly, does occupational therapy serve in this context?  The patient?  Or the government-patron?  Take a look at this other twitter-post from COT and decide:

/Edit: 3/23/16: Here is another depiction from the COT on what OT is supposed to accomplish:

Note that there is nothing in the messaging about improving function or quality of life for the patient.  Perhaps that is implied?  Who is the COT marketing to?  Are they marketing to the government patron so they know that length of stay can be decreased?  The COT provides a reference for this ability to reduce length of stay (Barnett, 2015), but it seems to be a rather stunning claim that needs further scrutiny.  Most OTs would argue that they could contribute to decreasing length of stay but I don't know anyone who would make a claim like this - it would be interesting to know how the researchers came to this statement.

 /EndEdit

From a US perspective, this is a confused approach that places therapists into what I call 'morally untenable zones of practice.'  Ethically, how is a therapist supposed to meet the occupational needs of their patients while at the same time meeting the economic objectives of their government patrons?

I understand that it sounds very noble to hear about 'care of populations' but this kind of orientation is actually very foreign to most OTs practicing in the US.  Do US practitioners think that they should have 'Saving Money' in their tagline?  Or that they should go out on ambulance rides and find ways to prevent hospital admissions?

I have great respect for all of my international OT colleagues and the systems that they function within but there is a deep and pernicious problem with accepting the methodologies of other countries and assuming that they are aligned with practice in another country.  Some occupational therapists have complained about 'colonial' attitudes of Western theories. (Hammell, 2011).  Certainly this concern travels bidirectionally.

The straw-man argument that is often used when I bring up this issue is "How can you possibly not be concerned about costs of care and improving quality?"  But remember - we should always be concerned about costs and we should always be concerned about quality (when it is properly defined) but that does not mean that we have to become stooges for a single-payor health care system and do their bidding to save money.  That is not the 'great idea' of occupational therapy (Reilly, 1985).

Simply put, you can walk and chew gum at the same time, but you can't do so when the government is defining 'quality' in your practice and basing it on economic terms.

I am concerned that some American occupational therapy leaders are not thinking deeply enough about the models that they are asking us all to support.  In another recent issue of AJOT we had more endorsement of population-based models (Braveman, 2015).  The author promotes further re-definition of the occupational therapy profession and states that we should "identify specific competencies related to population health and public health and include them clearly in the Framework."

Braveman proposes an expanded role for practitioners that includes policy work for non-profit organizations or in federal health agencies.  Certainly, occupational therapists can function within these roles but it is rather important to distinguish between the things that one might do with  occupational therapy training vs. what constitutes occupational therapy practice.  Suggesting that OTs work in these roles is fine, but suggesting that the PRACTICE Framework be changed is another matter entirely.  A different set of ethics is required when working with patients vs. working in the interest of public health.  One approach values autonomy and individual choice.  The other focuses on the good of the broad public (including its economic good).

In a previous blog post I laid out an explanation that population health models are focused on broad community needs and frame concerns in broad population statistics.  Occupational therapists have been carefully warned that public health models are incompatible with occupational therapy (Reed, 1984).  Specifically, Reed suggests that "occupational therapists must be careful to differentiate between the public health model and the health education and wellness model."  Unfortunately, occupational therapists are now confusing these models and in fact are even naming public health as a goal of occupational therapy.  Braveman asks, "How can we demonstrate occupational therapy's distinct value in improving the individual experience of care, improving the health of populations, and reducing the per capita cost of care?"

The answer to this question is that we can do it by socializing our health care system, aligning our purpose with the goals of the government-as-payor, and abandon our social compact to provide care to people.

That is incompatible with the current American system, and occupational therapists practicing in the United States are right to question if this is the correct direction for the profession in the United States.


References:

Barnett, D. (2015) From ‘assess to discharge’ to ‘discharge to assess’. What a difference a year makes! In: College of  Occupational Therapists (2015)  College of Occupational Therapists 39th annual conference and exhibition, plus Specialist  Section Work annual conference, 30th June–2nd July 2015 , Brighton Centre, Brighton, Sussex: book of abstracts. London:  College of Occupational Therapists. 25.


Berwick, D. M., Nolan, T. W., and Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27, 759–769. http://dx.doi.org/10.1377/hlthaff.27.3.759

Braveman, B. (2015).  Population health and occupational therapy.  American Journal of Occupational Therapy, 70, 1-6.

Hammell, K.W. (2011). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33.

Leland, N.E.; Crum, K.; Phipps, S.; Roberts, P. and Gage, B. (2014).   Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69, 6901090010p1-6901090010p7. doi: 10.5014/ajot.2015.691001.

Reilly, M. (1985). The 1961 Eleanor Clarke Slagle Lecture: Occupational Therapy Can Be One of the Great Ideas of 20th Century Medicine in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 87-105). Rockville: AOTA. 

Reilly, M. (1984). The importance of the client vs. patient issue for occupational therapy. American Journal of Occupational Therapy, 38(6), 404-406.