First Obama pushed for end-of-life counseling in ObamaCare, then it was pulled after Sarah Palin rightly pointed out the spooky nature of the death panels (you put this in as a cost saving feature of a bill and you’re damn right its a death panel). Then Dr. Donald “I love Socialism” Berwick, head of Medicare, put it back in…this time during the yearly Medicare checkups, and he tried to do it all sly like and back door the thing. He got caught and now Obama is pulling it once again:
Reversing a potentially controversial decision, the Obama administration will drop references to end-of-life counseling from the ground rules for Medicare’s new annual checkup, a White House official said Wednesday.
~~~The White House official said the administration is now pulling back the language because there wasn’t enough chance for all sides to comment on the change. The official spoke on condition of anonymity to discuss what has turned into an embarrassing episode for the administration.
Who is this Donald Berwick you ask?:
No one was surprised that a man of this character tried to quietly sneak this requirement into Medicare but still, wasn’t the whole hopey changey Obama thing supposed to include increased transparency? Yeaaaaah. So why the backtrack on this?
The general unpopularity of Obamacare has united conservatives and independents into a potential new political coalition that threatens to be the iceberg to the Obama administration’s Titanic. With repeal to be the first order of business for the House of Representatives, and a war of attrition likely to result against it when the Senate refuses to go along, it seems that the administration is trying to make Obamacare and its ancillary parts as small a target as possible. This is a sign of political weakness that should encourage repealers to keep pushing.
To put it plainly, Obama recognizes there is some real rumblings of discontent with ObamaCare and any issue which threatens to tip the scales in our favor is going to go down the drain.
Good.
See author page
I guess Sarah Palin was right, once again. (What a difference a Tweet makes LOL) Now we don’t have to go here–> LOL http://twitpic.com/oleru 🙂
Donald Berwick = scary dude
My home state has asked for a waiver for the entire state. I’m shocked no one has picked this up in the media yet.
Obama and Beriwck think the government knows better than you in all things, even when you the citizen is supposed to die. Delenda est Obama!
Anyone delusional enough to believe that “O” Care has any cost savings is not playing with a full deck.
There are both up front and hidden costs in that bad piece of Legislation and reductions in overall Quality of Care that warrant repeal of this travesty as a long term goal and not funding the thing as a short term solution.
With the Politically inspired exemptions for Some but not All, it is just a piece of Trash and a Cheap Trick on the Tax Payer that has paid into and are thus vested in MEDICARE. Either ALL are Exempt or NONE!
I have TRICARE and expect higher Premiums very soon. More broken promises but par for the course.
Should we be surprised at anything this out of control administration does? Now we get a whole new “Prez Staff” of liars, cheats and frauds. See we have come to distrust everything O-bozo does. We the People must stay alert for a whole new set of lies and obfuscation.
End of life counseling is not synonymous with death panels. Sarah Palin wasn’t “right” about this. Sarah Palin politicized it. As an oncologist (the medical specialty which accounts of most of the end of life counseling situations), I can spend five minutes with a terminal patient, prescribe yet another round of Taxotere, and make thousands of dollars a month doing this, or I can spend an hour explaining why Taxotere or anything else won’t help anymore. The end of life counseling proposal was simply to reimburse doctors for taking the time to do a difficult task. It was and is an entirely reasonable proposal. But then Palin turned end of life counseling into a death panel and it became politically radioactive. What I blame Obama for is backing down, rather than standing up tall and then having the guts to go to the mat for it.
– Larry Weisenthal/Huntington Beach, CA
Larry,
Objective counseling at ANY point in a patient’s life is absolutely a component of health care. Part of the problem is when you have administrators saying that maybe Grandma ought to just take a pill to deal with the pain instead of considering more expensive treatments that may not offer sunstantial benefit. The other part of the problem is that we are often too isolated from the actual costs of medical intervention (including counseling, diagnostic testing, and treatment.) It should be the patient and the patient’s family working with the doctor to decide what is best in any given scenario, including end of life care. I do not want my children to go broke paying for me to have a few more weeks of miserable existence made sufferable through palliative care.
This should NEVER have been an issue, but Medicare’s bean-counters and penny-pinchers have decided that they know precisely how many minutes every procedure and consultation should last. With too much emphasis on cost and not on patient care, the regulators have turned comprehensive health care into an expensive a la carte menu. Add to this that there is a palpable fear of eugenics because of the practices of many Socialist/Communist/Marxist regimes throughout history, with many Americans (and others around the globe) expressing concern over what they see as the descent of the US into Socialism. I believe it is unwise to discuss the full scope and potential of “death panels” or “end of life consultations” without acknowledging these socio-political concerns and relevant historical actions.
Sarah Palin and others have certainly seen that they can score some political points in the discussion, but it is a discussion worth having anyway, especially if our government officials are ever going to be as “transparent” as the ruling class would like us to believe they are.
Jeff
@Jeff. You are offering up a straw man with no basis in reality, e.g. when you say:
“administrators saying that maybe Grandma ought to just take a pill to deal with the pain instead of considering more expensive treatments that may not offer sunstantial benefit.”
That simply has no basis in reality.
Also, you say:
“Medicare’s bean-counters and penny-pinchers have decided that they know precisely how many minutes every procedure and consultation should last. ”
No, that’s not true at all. Or, at least, that’s exactly the way that all health care reimbursement works, whether in the private sector or otherwise. Getting paid in medicine is all about coding every last thing that you do; so that you can get paid for everything you do. This isn’t Medicare bean counting, it’s medical bean counting. And it’s not all that different from lawyer bean counting, except that lawyers bill by the minute for their services (as they are paid by clients and not by the insurance industry, in most cases), while doctors have to use specific CPT codes, which are found in a huge, huge book.
Just to get some idea, go to the following web site:
http://icd9cm.chrisendres.com/index.php?action=procslist
Click around, and you’ll see precisely how the system works. It’s not for the faint of heart.
In medicine, we actually have “coding conferences,” and we have experts in medical coding (akin to CPAs) who go through all the records, looking for overlooked things we do for which insurance companies (including Medicare) may be billed.
All “end of life counseling” would have done is to provide a Medicare code which could be used when such counseling took place. For most face to face patient care stuff, doctors have the freedom to code such interactions as “brief,” “limited,” “extensive,” “complex,” etc. so there is no rigorous directive from bean counters on how long the interaction should take place. Rather, the doctor does what the doctor does and then bills for it. Only doctors are now not reimbursed, under Medicare, for providing end of life counseling. Human nature being what it is, doctors will, in general, have a negative disincentive to do this, as most doctors are overworked as it is and it’s tough enough to do stuff for which one is paid, to say nothing of having to do stuff for which one is not paid.
Eliminating “end of life counseling” as a service for which a doctor can receive compensation hurts the patient and “protects” no one.
– Larry Weisenthal/Huntington Beach, CA
Obama’s death panels exist only in the imagination and the propaganda of the right-leaning media.
Governor Jan Brewer’s Arizona death panel, on the other hand, exists in reality, and is already up and running. From Forbes, dated January 5, 2011:
You’re probably not going to hear about it on Fox News, or read about it in any Rupert Murdoch publication.
http://blogs.forbes.com/rickungar/2011/01/05/arizona-death-panel-claims-another-victim/
That was the second victim of Brewer’s Arizona death panel, btw.
Two down, 97 to go.
Greg;
Sometimes you might actually have a good point to make, then you poison it by spouting off about right wing crap. Common on man wake-up and realize that the people here are first and foremost American Patriots. Do you think your winning friends by spouting off about Right wing crap when most of the people here are just conservatives and only want the MONEY to be spent where it should be spent. Wake up . . . the only difference between any thing is that one has been implemented and the other is actual. So the question that you really present is WHY this happened in Arizona . . . maybe it was because the LEFT wing did NOT properly fund it, come on, because they were to busy building the TSA. Get real man. Take away the “touch me, feel me” TSA picture machines and guess what . . . maybe the persons life would have been saved . . . instead of feeling up the airline travelers. So clearly to me, feeling up airline travelers is more important to YOU LEFTIES than is saving a life.
In case you didn’t read the reason for “…the backtrack (as Curt puts it) on this issue….”, here it is straight from the NRO:
“The renewed debate over “advance care planning” threatened to become a distraction to administration officials who were gearing up to defend the health-care law against attack by the new Republican majority in the House.”
Simply put, the administration thought that Palin’s lies–which are bought hook, line and sinker (without any thought) by conservatives–might overly complicate any up-coming legal defense of the bill. Perfectly reasonable.
@liberal1 (objectivity): Thanks Mr. (SUBJECTIVITY).
I smell a Truckload of BIAS & Propaganda, like a gas main that is leaking…in Your Head…
@liberal1 (objectivity):
So, basically, you’re admitting that the Brain TrustTM at 1600 has a complete inability to defend their legislation against its’ critics….even when said critics are supposedly “lying”.
Simply put, they got caught with their pants ’round their ankles. Again.
Exit Question: What are your thoughts on IPAB, Federal Coordinating Council for Comparative Effectiveness Research, and the National Coordinator of Health Information Technology?
@Aye: (#15). I’m totally pissed that the Administration caved on this!
LW/HB
@openid.aol.com/runnswim: Could they pay for it?
Despite the very Obvious benefits, would it buy any Votes?
@liberal1 (objectivity):
Alas, it is perfectly reasonable. It’s also a sad comment on how easily simple lies can be made to prevail over more complicated truths.
I’d like to see the Obama administration take on every lie as a matter of principle. Unfortunately, there are so many that doing so wouldn’t leave time for anything else.
Yeah… I’m pissed too that we don’t get to spend an additional $5 to $10 bil more annually in 2011 (and growing, based on increasing Medicare enrollment) on Medicare in order to pay doctors for consulation on what anyone can accomplish via downloading their state directives, plus (maybe, depending on state regs) the price of notarization. Gee… what’s an IPAB death panel gonna do for their salaries? /sarc
@Greg, are you so dense to miss the obvious? When government insurance is statist run, the cuts have to happen when taxpayers can’t afford to pay for someone’s liver transplant instead of their private insurers.
In the former’s case, there is nothing to do but institute further death panels. In the latter’s, they find a different private insurer.
Glad you’re figuring it out… sorta.
BTW, INRE @my comment above and increased Medicare spending for doctor “consulation”… see my post and figures in response to Billy Bob on another thread. Of course, Larry may complain since I don’t have a graph to draw the wrong line in… not that it changed the figures in any way, of course.
Since then, Billy Bob upped my estimated doctor billing for consultation from $120 per consulation estimate to $200… inflating my original figures. DOH!
Yeah! Let’s spend MORE! Forget all the cheap, consumer direct routes! After all, the IPAB has to have some cuts to recommend, right?
@MataHarley, #20:
What’s obvious to me is that the Arizona approach is forcing certain seriously ill, uninsured people out onto the ice flow to die–and that they actually are dying. I have also observed that some who find this approach acceptable also want to eliminate the healthcare reform provisions that would make it possible for such people to acquire private insurance.
What am I supposed to conclude from this?
Actually, what is apparently *not* obvious to you is that the AZ government insurance … i.e. statist/government run insurance… is forcing people out because it’s funded on the backs of all taxpayers who can’t support the load. Thus the lesson you still have yet to learn about government provided insurance, I guess. Despite the obvious lessons of both AZ and MA, which can’t afford it’s hoity toity statist plan.
You may have “observed” some approach, but I have no clue what it is. HIPPA laws since the Clinton days have federally prohibited any insurer from denying coverage for pre’existing conditions for group insurance plans more than 12 months maximum. What’s the catch? The lib/progs don’t talk about HIPPA and group plans. They talk about the few percentile that obtain individual private insurance plans.
What’s the answer? Make everyone eligible for a “group” somewhere. (i.e. create more “groups” people can participate in) Perhaps lessen that 12 months to 3-6 months for pre-existing denial maximum. Not unreasonable. Most insurance plans have a qualification period anyway before coverage begins. Problem solved.
Obamacare is a blight on this country. Berwick is a classic example of someone who should never have this much power.
I wrote about him last year on my blog and quoted him:
Mata Harley’s ideal of Medicare policy for end of life counseling:
Cancer patient: Well, how’s it looking Doc Harley?
Dr. Harley: Buggers, you’re cancer is growing again.
Cancer patient: Well, what are my options?
Dr. Harley: I can change your chemotherapy or else you can go to the website on this business card and read about the sorts of things you could do instead.
Dr. Harley: NEXT PATIENT!
Larry How long does that take? Should the doc be paid to say “your cancer is growing again, here’s your options…”? Or is diagnoses and treatment options an extra charge, Larry?
To decide to live with option treatments or decide to die with dignity is not a doctor’s decision. It is that of the patient, their family and/or their clergy. But I guess you want them to be paid extra, on an annual basis, for the diagnoses and not-so-pep talk.
Whatever, Larry.
Sounds like Larry likes ‘Ole Donny Berwick.
Two peas in a pod.
Mata, it is just not nearly as simple as you make it out to be. Walk a mile in the doc’s moccasins and do the thought experiment to see how it really does go, in the real world. You say it should be the patient and family’s decision. Number one, you are wrong in thinking this, 95% of the time. 95% of the time, in the real world, the patient and family decide to do precisely what the doc wants them to do. (Parenthetically, this is the reason why the classic capitalist economic model breaks down at the level of medical care: the sellers make the purchase decisions for the buyers. For example, what is happening now that there are more unemployed people without insurance is that the employed people with insurance are now receiving more medical services. They aren’t suddenly sicker than they were before the recession; it’s just that the doctors have fewer paying patients and need to make up the shortfall).
1. Continue with same chemotherapy.
2. Change to different chemotherapy.
3. Have more surgery.
4 . Have radiation therapy.
5. Go on a clinical trial (where the doc selects which of a half dozen clinical trials most need patient accrual).
6. Discontinue further treatment as futile.
If a doc wants to be conscientious and seriously offer an option between further treatment and supportive care only, then this takes a whole lot of face time, explaining, point by point, what each of these entails. You can’t just send the patient off to a web site. It is actually a gut wrenching experience for a doctor to have this sort of a conversation. It’s so much easier (and far more remunerative) to simply say, well, that didn’t work as we wished, but now we are going to go onto plan B, C, D, E, whatever.
End of life counseling isn’t about living wills — it’s about end of life counseling. Which is very complicated.
– Larry Weisenthal/Huntington Beach, CA
Living wills and advanced directives are two different legal critters. Neither one demands a doctor’s opinion until the real event is staring patients in the face. At that point, the patient may opt to change their mind about their directives made when they weren’t staring down death, or not.
Now, what are the repercussions of advanced directives? Are they reversible? If you go to NoQuarter and check out their threads, you will find nurses and military wives who speak of doctors refusing to alter directives at that moment. Can that advance directive be used to deny coverage? If unaltered, of course. It’s what they are banking on.
You over estimate a doctor’s input in the end of life decisions. We ask for the prognosis. You give it. We decide how to proceed. It doesn’t take annual paid visits, it is alterable in the patient and family’s mind if they opt for life prolonging instead of death, and it’s part of a doctor’s job…. for which he has already been paid.
Oh yes, might I add that after the doc collects their annual visit billing/fee, they’ll give them a free printed copy of the same directive the patient could download for no cost at the site to fill out.
>>You over estimate a doctor’s input in the end of life decisions<<
You are naive.
And all the stuff about advance directives, etc. is a distraction. And you don’t go scheduling a visit to do end of life counseling. That’s ridiculous. It happens in the course of ongoing medical care.
It’s simply about giving a CPT code for a very important service. Not paying for it is being penny wise, pound foolish, and cruel to the patient, who is the one who ultimately bears the burden.
You think end of life counseling is about advance directives? That’s not end of life counseling. The former is about a two minute conversation. It says, if something goes wrong and you go into cardiac arrest, do you want us pounding on your chest, giving you electric shocks, and putting you on a ventilator? That’s entirely different from deciding whether or not treatment should be continued, changed, or abandoned in favor of supportive care only. This can easily be a one hour conversation.
– Larry Weisenthal/Huntington Beach, CA
Whatever, Larry
Maybe you should research the legal differences between a living will (which is as you described) vs an advanced drective, Larry.
Then, maybe you should consider that a decision made in a seemingly healthy moment may differ from the other moment a patient and their family face imminent death, and then may chose to fight for prolonging life over a directive made prior to facing that moment in time.
Doctors have been doing end of life, via federal mandate and services rendered in good conscience, for decades. And as part and parcel of their service as a medical doctor in ERs everywhere. What people decide yesterday may not apply when faced with that moment today. And that decision isn’t based on the doctor’s counseling on whether they want to live or die. A doctor comes into play for the options only.
As I said before, bring me your car. I’ll be happy to diagnose it, then charge you extra to tell you about your options for repair.
In reality, whether you decide to junk the car or repair it, is not the mechanic’s decision or counsel, but that of the car owner and whomever he/she chooses for added advice. The car owner only uses what the mechanic offers as options to make their decision. But I’ll tell you what… why don’t you make the decision to junk the car today, before it breaks down tomorrow, because I told you it may suffer problems.
The burning question is, will your insurance cover the repairs of your car when it differs from your “advanced directive” to junk it?
@ anticsrocks, #24:
I’ve been puzzling over that statement for several minutes, trying to figure out what part of it isn’t true.
Keep puzzling, Greg. Hint for you… it’s likely to be found, with historic documentation, in the two words, “excellent healthcare”…. which will then be followed by the next two words not spoken – “fiscal folly”.
@anticsrocks: Wealth has ALWAYS been redistributed in the provision of medical care. Back in the 1940s and 1950s, when most people didn’t even have health insurance, the rich people paid higher fees to cover the costs of poor people who could afford no fee. This is the way that health care has always worked. Only today, health care is much more expensive and the system is totally out of joint.
Police and fire are redistributional, by your definition. National defense is redistributional. Rich people pay more taxes than poor people, though all get the same level of police, fire, and military protection.
– Larry Weisenthal/Huntington Beach, CA
@Mata. We are going around and around and I am going to bed. Good night.
– Larry W
Rats, had my shower all taken, teeth brushed, and on my way to bed, when my Android phone tells me that Mata has posted two more comments…
Mata, you really don’t understand what end of life counseling is all about. Living wills and advanced directives refer generally to the exact same thing (don’t take my word for it, just Google it; you are creating a semantic argument about things which really have little to do with end of life counseling).
Living wills/advanced directives are things which EVERYONE should have; you and me included. They pertain to unexpected situations, where something catastrophic happens. What types of extraordinary care and procedures do we want? If we become incapacitated, who makes decisions on our behalf. And so forth.
This is very different from a patient with a terminal illness (the most common of which is cancer). In 50% of people with heart disease, the first symptom is sudden death. The remainder are customarily treated with state of the art, full court press medical care until the very end. It’s mainly with cancer patients does the time come to decide, do we press on with treatment or do we provide supportive care, and what, precisely, does supportive care consist of? These are very difficult and complicated conversations to have with patients. The expenses associated with the care of cancer patients in their last year of life are horrific. Too often, the suffering is horrific, as well.
As I wrote before, all the economic incentives for the doctor are in providing care. This is in line with the emotional incentives, as well. It is very unpleasant to have to tell a patient that you have basically failed and that you have nothing left in your armamentarium which has any realistic chance of improving the patient’s state of well being — beyond humanely supportive care. Again, just do the thought experiment of imagining how the conversation would go, were you the doctor in question.
All the things which doctors get paid to do (and, again, I encourage you to peruse through the thousands of CPT service and billing codes), end of life counseling is one of the most worthwhile and important. It should be encouraged.
– Larry Weisenthal/Huntington Beach CA
@Larry: You said:
That’s an amazing story Larry. Got any proof? If so I will be the first to say you are right about that statement, but at least back up what you say.
Sorry Larry, but I’ve got to side with Mata on this one. It is just stupid to pay for the consultation of options concerning end of life decisions. You may see this differently; big surprise there.
Bottom line is that the government needs to stay the hell out of private decisions and discussions between doctors and patients/patients’ families.
@Greg: Keep puzzling and maybe someday (not likely) you will realize that when the government makes itself the sole provider of healthcare, then the redistributional part means that rationing will be imperative. Name ANY country that has socialized medicine and has been able to avoid rationing. Hint: You can’t because there isn’t one.
@anticsrocks:
You know…Greg amuses me.
If he’s so concerned about these transplant patients…and is so convinced that it is the duty of fellow citizens to finance their organ transplants…just how much of his own money has he donated to them to help out their cause?
I doubt it’s even a penny.
@Aye – Yeah, seems that liberals are very generous – just with other people’s money…
I really don’t understand what I’m talking about? That’s a good one, Larry. As you personally know, I have lived the end of life passage for the past two years, first helping my parents get it squared away for my father, all the way thru to being one of the primary care hospice providers in his last days. This all transpired over a year’s time. Therefore I’ve had plenty of first hand exposure to end of life planning.
You shoulda quit while you were ahead, and just tucked your kepi in bed. Because to say living wills and advanced directives “…refer generally to the exact same thing” indicates your Google talents are perhaps not as stellar as your lab abilities. You might as well say a quitclaim deed is generally the exact same thing as a statutory warranty deed because, gee, they’re both deeds, right?
But hey… don’t take my word for it. I assume you’ll give the Mayo Clinic some due respect?
The advanced directive is a much larger plan, and the living will… dealing only with whether they’re pounding on your chest, as you say… may be one documented part of that advanced directive. While it covers a wide array of options for what to do under what circumstances even when not in a “chest pounding” moment, the largest difference is that the advanced directive allows for appointing a health care representative or one with POA as your mouthpiece, while the living will does not. It also goes into more depth about treatment preferences long term than the living will.
I’m certainly not against planning for the end of your life. It was important that I helped Mom get thru this while Dad was still alive since, when the moment arrived, she and my father may not be as clear headed. I’m just saying that a doctor, helping you to plan for something that has not yet arisen in real life, is vastly overrated. In our family’s planning, the doctor had minimum involvement. Thank heavens because, in the end of days, she refused to prescribe pain medication for my father. Hospice made the request a week early so that, when he began to experience pain, it would be there and ready.
For over a week, and after three refusals, hospice had to wait out the business day in his last 24 hours of life, then get the pain medication thru the hospice head doctor and their pharmacy after hours. He got his first medication for pain six hours before he died, and needed it days before that.
Would I want that physician involved in my parents end of life decisions? No. Because you like the medical services of your primary does not mean you consider them honored counsel for such personal matters. And, in fact, they are not needed save for the specific medical treatment for the moment, and their suggested options.
As the NYTs pointed out in April 2009, getting an advanced care directive is not complicated because the forms are easily available, and notaries are not always required… depending upon the state regulations. The longest and most painful process is the family members and prospective patients, discussing how and under what circumstances they wish to proceed. The problem is, you can only envision so much, and everything may be subject to change in the ER when the moment arises.
I will also note that the NYTs also made reference to the battles with doctors, even with an advanced directive. By law (PSDA), they are supposed to advise patients of their rights, and to honor those wishes. Doesn’t always happen so smoothly.
I mentioned that there were some very good comments on a thread over at No Quarter. One that stood out in my mind was from a retired nurse, Helen. And I hope she doesn’t mind me cross posting her most excellent observations here.
Yes, you can’t predict what hasn’t happened yet. Nor can you predict today what you may want tomorrow. Today I may say I want a DNR under all circumstances. But then, with a fluke of an accident and a moment of me slipping away that could potentially be averted with CPR or the paddles, I may want to live. With a living will, they’d let me expire. With an advanced directive, a family member or appointed representative may understand this is not the usual situation we had envisioned, and the injuries or prognosis don’t warrant the no code measures.
Also on that No Quarter thread was a commenter, armymom, who works for a doctor. Advanced directives are supposed to be alterable on the spot, as the situation warrants and to the wishes of the patient or their representative. She notes that they did not allow her father to change his directive, and had a problem with two relatives as well.
So what happens when you make a directive, and you want it altered? Can you say, with absolute certainty, that after having a directive for years that states, in essence, “let me die” that your government insurance may not use that last minute change as a reason to deny payment for treatment?
If you are honest, you can’t have that certainty. Because you cannot predict what a panel like the IPAB may come up with for solutions in order to keep Medicare on budget. They cannot legitimately deny treatment by the limitations of their powers, but with an advanced directive, we now get into a grey area. Does that advanced directive on record for years take precedence, and give them the out for denying payment… saying they are merely conforming to the patient’s wishes?
Now before you do a “tut tut… you’re being an alarmist”, this is not out of the realm and can best be exampled by a patient who decides to opt out of hospice, and resume life sustaining treatments. If he/she does so, they forfeit any Medicare coverage for the remaing duration of their 60-90 hospice elective period. Meaning, that if I opted to have treatment to sustain my life – which can be something as simple as hydration – but then a week later see that it’s futile, I cannot return to hospice and have the Medicare coverage until I wait out that elective period… assuming I had that long.
In short, the Medicare program regulations allow very little flexibility INRE coverage. Similarly, we simply do not know how these directives will affect future coverage.
But we know one thing… they will be desperate to save every penny possible, and I see the probability of these directives being used to achieve that end.
@ anticsrocks, #39:
Are you laboring under the delusion that the rationing of health services doesn’t already exist for anyone who lacks insurance and has no money to pay for the skyrocketing cost of services?
Are you laboring under the delusion that rationing doesn’t also exist for many who have health insurance? That doctors are able to freely determine what diagnostic tests they can order, what treatment they can provide, what medications they can prescribe, etc, without any consideration of what profit-oriented insurance company rationers will agree to pay for?
Are you laboring under the impression that anything about O’healthcare does whit to reign in the skyrocketing costs of administering medical services?
Or do you think price fixing premiums cures that?
@Greg:
Nice way to avoid answering the question.
This dead horse has been beat so much, it is paper thin by now, but once again let me reiterate that when your private insurance company denies services, you have recourse. In fact, you have several. When the government is the sole provider, who do you turn to once they deny service to you?
Stop with the liberal talking points and if you wish to debate this discussion of rationing, then at least be intellectually honest. Now answer the question –
What country with socialized, government run medicine has been able to avoid health care rationing?
@mata. You are obsessively hung up on the Living Will/Advance Directive (and that IS simply a semantic distinction — it’s all part and parcel of the same general thing; there is no “official” distinction; language used in the Mayo Clinic is not necessarily the language used at Memorial Sloan Kettering or anywhere else). The living will/advance directive part of it doesn’t need a physician, IF it could be considered in isolation, which it can’t be.
Firstly, what went into the proposal for end of life counselling was this:
“paying physicians to talk to Medicare patients about living wills, durable power of attorney, palliative care, and hospices”
http://www.medscape.com/viewarticle/734949
Note that the language “advance directive” isn’t even used, in this case. As I said, you are trying to score some sort of “points” with fine semantic distinctions which don’t even exist.
Secondly, you are obsessed with the “living will/durable power of attorney,” etc. part of it. In point of fact, that is a VERY SMALL component of the overall process. Much more important are the discussions about palliative care (or, as I called it earlier “supportive care”), including, but not limited to hospices.
In the real world, you are talking about decisions between active treatment versus supportive care. You have to go through the pros and cons of each, carefully, and answering all of the many questions. There is no reason why doctors should be required to provide this service for “free.” As I wrote before, this can easily take up to an hour, in some cases, or, in other cases, a half hour over two visits (the first to present the information, then to give the patient time to think and consider and come up with additional questions to ask). This cannot be done by ancillary medical and social work personnel. It is during this general discussion that the physician should appropriately ask: “do you have a living will?” and then explain it to the patient, if the the patient doesn’t have one or to go through what’s in the existing living will, if the patient does have one, and determine how this should, perhaps, be modified. As I wrote earlier, however, this is a VERY MINOR component of “end of life counseling!”
You should understand the point of view of physicians:
http://www.medscape.com/viewarticle/734949
– Larry Weisenthal/Huntington Beach, CA
Oh for heavens sake, Larry. Why is it you prefer to parse terms and not accept the legal realities and repercussions of a patient’s choice between a living will and having a health care proxy vis a vis a more thorough advanced directive? As the the legal terminology notes,
*Supplement* a living will. It is not part of the living will, and thus becomes another document in the more complete package known as the advanced directives.
Mount St. Mary’s Hospital has this on their site INRE living wills and proxies:
Were I to have a living will, that instant I mentioned above – slipping away after a car accident when I could probably recover if someone applied code – leaves me no options. They let me die. With a health proxy there to make the decision for me while unconscious, I live. That is why the commenter nurse, Helen, noted she wanted to be kept alive until her proxy could get on the scene. Without that extra documentation, she’d be long gone.
Thus if you, as a physician, decided to counsel any of your patients into a “living will” instead of a directive that includes a proxy empowered to assess the unknown circumstances, you have just done a major disservice to your patient by your lack of legal knowledge in end of life counseling. Thank you for that example that even medical professionals who consider themselves competent in this arena, aren’t.
You still cling to this illusion that only doctors seem to be able to provide this counsel. And that, in itself, is offensive. This is a personal decision, aided by family and perhaps clergy. Unless your doctor happens to also be a very close confident, they are the last people I want involved in my end of life decisions.
I understand full well where physicians are coming from. They want to get paid. In fact, a doctor weighed in on the No Quarter thread I linked, whining about not being paid. Said he’d provide it for free about the same time a lawyer provided consultation for free. Another noted her doctor found it offensive, and considered providing information that they had rights for end of life treatment was simply part of the options when discussing treatment. Therein lies the conflict of interest in even approaching any physician for this counseling. Nurse Helen is right. This is either a family issue, or of you have none, a social counselor. It needs to be kept out of the hands of doctors, who have too many conflicts of interest… and apparently too little legal knowledge to do their patients justice.
Good grief, Mata. Give it up. What we are talking about is “end of life counseling” or “advanced care planning.” Living wills and durable powers of attorney and advance directives are all part and parcel of the same thing, and, collectively, are a VERY SMALL component of what goes into “end of life counseling,” which is mostly about the decision whether to continue with active treatment or to go with supportive care and all the various considerations — pro and con — which apply to each and what each entails, in the context of the individual patient’s disease. In the course of doing all of this, living wills and durable powers of attorney come up, but it isn’t the function of the physician to actually draft these; it’s simply important to bring them up — do you have them? Do they need to be modified in the context of the “advanced care planning” which we are now doing? But, again, this part of the process is only a very small component, and the much larger component (explaining active treatment options versus supportive care options) is something which can only be done by the patient’s physician.
Once, just once, I would like to see you acknowledge that the person with whom you debate these things actually does have a valid point of view.
Your entire discussion about whether or not tax cuts pay for themselves (and they most certainly do NOT, as shown in the very study you yourself cited) was stubbornly pertinacious. That’s what triggered the “whatever.”
– LW/HB
Gee, Larry… this is already mandated by the PSDA (Patient Self Determination Act). Patients are to be advised about their rights to continue, or refuse treatments. This isn’t extra, and has been done for decades as a part of a physician’s service. Now they want an annual review?
Hey, why not spend cash printing a pamphlet explaining the basics in options for end of life directives? The doc doesn’t have to spend time talking about something that has a direct conflict of interest. If there is something about a patient’s condition that has changed, that’s all part of their usual diagnosis/prognosis. It simply does not take all the doctor input you purport. And in fact, how long does it take to say, “do you have them”, and hand them a pamphlet filed with resources?
I’m not sure what you want from me. Do we agree that end of life planning is important? Of course. Do we agree that the principal figure in that planning is a physician, who should be paid for his time? No. Am I impressed by your own grasp of the documentation INRE end of life planning? Nope. Do I respect you and your expertise, other than in this arena? Certainly. That’s about it in a nutshell.
INRE the tax debate… what the figures showed was that the Clinton policy of raising taxes, combined with the choice of tax cuts he decided to implement, “lost revenue” (in the way you think of lost revenue by not increasing the amount the goverment will take from earners…) and was in a decline for his terms. The Reagan policies that also included both tax cuts and tax increases also resulted in “lost revenue” (see above for disclaimer), but show an incline throughout his terms. Reagan was in a dire straits economy, inherited from that idiot, Carter. Clinton enjoyed boom times from two bubbles, and still managed to show a decline in tax revenues.
I’d ask what’s your point, but it’s off topic, and I have no desires to return there with you. We fundamentally differ on whether the nation’s earnings are up for grabs by the government, in order to support their irresponsible spending habits.
@ anticsrocks, #45:
You seem to have missed the point of my reply. I’ll try again: The question is bogus. Every country rations health care. What differs is how it’s rationed, and what the effect on the quality and availability of health care is.
In modern industrialized nations other than the United States, health care is rationed based upon a prioritization of medical need. Everyone is eligible to receive a defined, broad set of core services. Intensive levels of care are also provided, with humane and rational consideration of cost vs. potential benefit to the patient. Much more emphasis is placed on preventive medicine, since that’s the best and most cost effective approach to keeping people healthy. If longevity is any indicator of the overall effectiveness of healthcare systems, this approach would appear to work well. Citizens of other modern industrialized nations live longer, healthier lives than we do. In terms of longevity, the people of the our own nation currently rank 29th.
In the United States we ration by ability to pay and have the most expensive health care system on the planet. We aren’t so oriented toward preventive medicine. Our system tends to let people who can’t afford routine care get very sick indeed before they have access to medical intervention, often at great expense and less effectiveness. Medications can cost a fortune and we carefully protect those enormously inflated costs, even when the taxpayer is footing the bill.
If you’ve got good insurance or a lot of money, it’s probably the best healthcare system on the planet. If you don’t, you might not have access even to basic medical services.
So, what’s your preferred form of rationing?
openid,aol.com/runnswim hi, with all respect for your difficult position to deal with
very sick patients, why take away the last hope for a still alive person,
who carry behind him a lifetime of hope for anything concerning living and having a future,
most of those people have fed the GOVERNMENT all their life,some of long life,
they tought that they would have the needed care and rightly earned until the end made as loving as they deserve, without breaking their spirit before they the endof the last breath
further more, donrt you get paid enough that you would debase yourself to accept a fee for couseling any counsel about life and death? as you know the death follow in the mind of everyone from birth to the end so why bring something which is already in the mind of a person sick at the hospital or at home in a VULNERABLE SITUATION,
BEST TO YOU FOR 2011
@bees: You ask:
That’s the precise reason why end of life counseling must be included in comprehensive health care reform.
It is SO easy to simply keep treating the patient with a never ending armamentarium of drugs and radiation and surgery and clinical trials — literally right to the bitter (and too often painful) end. All the incentives are to do this. The patient wants “hope.” The family wants “hope.” The doctor wants money. The doctor gets much more money when he treats patients than he’ll ever get out of a 30 or 45 or 60 minute doctor visit to discuss the pros and cons of continuing with active treatment versus supportive care and what, precisely, supportive care means in his particular situation.
Humans are remarkably resilient and even courageous. They can and do handle the truth. It’s always their choice, whether or not to proceed with further, active treatment, and no government death panel is ever going to take that choice away from patients. But an informed choice requires knowledge, and the only way patients can get that knowledge is to have their doctor sit down with them and explain their situations and go over the details of the alternatives.
There is vastly more in the way of transparency and public accountability regarding health care decisions in the context of Medicare than there is in health care decisions involving private insurance. That’s what people don’t understand. Patients and doctors have to deal with gatekeepers in private insurance, but not in Medicare. There is virtually unlimited choice among providers and hospitals with Medicare, but this is much more restricted in the case of private insurance. And there is much more payment-related “rationing” with private insurance than in the case of Medicare.
The best health care system for America would, in fact, be Medicare for all. Eventually, we’ll figure this out, and, someday, that’s what we’ll have.
On another thread (started by Curt), Dick Morris tells Republicans what they must do to defeat Obama in 2012. One strong warning he gives Republicans is this: “Don’t mess with Medicare.” That’s because Medicare has the highest consumer satisfaction rating of any insurance plan.
– Larry Weisenthal/Huntington Beach CA
So again, it comes to exactly what I said it was. You want the doctors to be paid to explain the diagnosis and treatment options. Like I said, bring your car to my mechanic shop. I’ll run the diagnostics and come up with some solutions for you, but I’ll only tell you if you pay me extra.
Your father’s Medicare from a medical service provider standpoint? Possibly… and perhaps debatable. I have a primary care giver for her parents who’d argue that with you until the cows jumped over the moon. But then, your father’s Medicare is not to be our Medicare.
From a fiscally successful standpoint? Not even remotely the “best health care system” since it’s unsustainable. Ponzi schemes always are.
Like they have a choice? Mandated enrollment, or opt out and give up your Social Security checks. Yeah… some choice. There’s only hamburger available at the restaurant, and not steak. Am I happy with the hamburger? Well hang, yeah. Better than starving, don’t you think? And since those on Medicare today have had their earning absconded for a health care insurance they can’t use until they are 65, it’s also the only way to get some of their cash back.
Now, since I know you’ll come back with how much more money in benefits they get than they put in, let’s give you a reality check. If I have my house insured for $200K, paying a $500 premium annually, and my house burns down after 10 years, have I paid in more than I get back? Nope. If my house never burns down, and I keep it until my dying days, do I get any benefit from my premium payments? Nope. But at least, when I pay my premium, I have some coverage.
Insurance has always been about risk spread. A gamble the company takes that they will be collecting more premiums from many that outweight the payouts of a few with claims. With Medicare, it’s entirely different. They are collecting premiums from those who get no benefits for decades… and with no promise the system will be solvent when they reach the age of eligibility. In short, they pay, get nothing, and have no guarantees they will ever get anything. Many die long before they ever get to the age of eligibility.
Instead, the money is collected from those who are not covered, to pay for those who are.
Medicare needs to be phased out and transitioned for the young. The same with Social Security, also suffering from insolvency, and merely just a piggy bank for an irresponsible Congress to spend, replacing it with worthless IOUs.
openid.aol.com/runnswim, further more why diminish the medecine or care before the end,
it bring to my mind a way for OBAMA to take from the old or sick and redistribute it to where he get his votes, illegals the youngs who are teach to adore him like a god which he ‘s not by far,
IT’S so telling that we cannot escape to see it
bye
@mata:
Of course they have the RIGHT to continue or refuse treatment, but they can’t make an intelligent decision unless they understand the facts of their situation. And, no, they don’t want an annual review. The proposed statute simply said that they would pay for an “end of life” or “advanced care planning” session A MAXIMUM OF once per year per patient. That’s just common sense.
What the study you cited showed was that every single tax cut was associated with a tax revenue decline, while every single tax increase was associated with a tax revenue increase. In that same long thread, you castigated me for changing the subject. The subject was whether or not tax cuts pay for themselves. Answer: No, they don’t. The subject was NOT was Reagan or Clinton the better President, with regard to management of the economy.
All you had to do was to simply acknowledge the fact (supported unanimously by the 10 conservative economists cited on the thread, and supported also by the very data you cited but incorrectly interpreted) that tax cuts don’t pay for themselves, and then you could have raised an issue for a new thread: “Resolved, Reagan was a better President than Clinton,” or whatever. But you couldn’t just do that. After castigating me, repeatedly, for (1) failing to address your alleged “smoking gun” of a citation (of which your interpretation was totally wrong) and (2) for changing the subject, rather than addressing the issue at hand. Well, when it turned out that you were wrong, you simply changed the subject.
– Larry Weisenthal/Huntington Beach, CA
Well Larry, of course a “tax cut” results in the government collecting less revenue. If I rent you your lab building, and reduce your rent by $500, I’m getting $500 less. When you put something in that simple of a context, it’s a no brainer. “Mata, is the sky blue? Why yes, Larry… it is. Unless you want to include those clouds over there, and the colors of the setting sun… in which case, it ain’t all blue”.
Were that tax policies so simple.
The point is, is any particular tax policy more effective in increasing overall revenues by allow earners to increase their individual earnings? That answer is yes… and demonstrated by Reagan’s combination of tax policies, and proves how Clinton’s tax policies resulted in declining revenue.
Which is why Obama’s economic council is suggesting a similar tax reform that was used by Reagan… the balance of tax cuts to the earners, and tax increases or removal of write offs to businesses.
Now, last from me on this. Not interested in going this far off topic.
First of all, there is no “proposed statute”. It was a Medicare regulation. I have not seen the specifics of that regulation, or it’s exact language, reproduced anywhere. Have you? Were there any other stipulations about payment if that annual counseling did not take place? I don’t know. None of us do since they didn’t pass the regulation language on to the public.
What you describe is what was originally proposed in the O’healthcare prior to passage, but change the visits to once every five years. Again, even that didn’t have the specifics of regulations attached since they hadn’t been passed on to the Medicare agency for those details. We have no idea what would be attached, based on the bill’s original language. As I always say, devil in the details…. just like you probably didn’t know if you opt out of hospice, you lose your coverage for that period and can’t return.
openid.aol.com/runnswim , yes on your point of view as your vast knowledge lead you,
and yes to the reality of the patient courage and ability to receive the truth,
what is your assurance of how many days left to live, some truth can fall beteen the cracks
and survive longer, AND I MAINTAIN THAT the vulnerability of the person is top
consideration and not to be made worse, as he is being handle by many diffrent aids,
given shots in his weaken body which hurt for he is to frail and not equip to have that kind of discussion from the doctor he has trusted with his life not his death which belong to him alone to keep in his mind,and discuss only when he want to not before
@ Mata. Medicare is not a “ponzi scheme.” It’s health insurance, with the broadest possible risk pool (the entire population), which makes it the most sound and efficient. Medicare has the lowest health care costs and delivers the best outcomes. And provides the best consumer satisfaction rating, your “primary care giver’s” opinion notwithstanding. The only reason Medicare has funding problems is that it can’t raise it premiums by 30% in a single year, the way that private insurance can. You take away Medicare, and what are you going to replace it with? Anything you choose will cost more and deliver less.
– Larry Weisenthal/Huntington Beach, CA
Been here, done that with you, Larry. If it were a “health insurance” policy, I’d be able to have something for my cash payout.
As it is, I’m paying out for a “health insurance” policy today that I can’t have until I’m 65. Therefore, it’s not “health insurance” because I get nothing for my contribution and, in fact, when I do become eligible, will have to pay even more. The best picture you can paint on this clown face notion is that I’m paying for a reservation to get a health insurance plan in the future that may, or may not, be solvent… and that I may, or may not, live to enjoy any benefits.
In the meantime, the government is taking my “reservation” money, giving me nothing, and paying for others health insurance bills. The first enrollee into Medicare didn’t pay in but 2-3 years maximum… certainly not vested with any reasonable amount of time. But the government didn’t care… they were busy collecting my “reservation” money to pay for the early “investors”.
Ponzi scheme… per the SEC’s definition:
Let’s try that again, with a bit of editing:
I posted this on the Open Thread, but it fits better here:
More here:
http://spectator.org/blog/2011/01/07/breaking-cbo-says-repealing-ob
Halleluyah! I am saving this quotation forever, and the next time I’m arguing this issue with Aye or Hard Right or Missy or any of my other friends on this particular blog, I am going to toss that right into their laps.
Free at last. Free at last. Lord, Lord. Free at last.
I have climbed the mountain and seen the promised land.
Thank you, Ms. Harley. Thank you. Thank you. Thank you.
– Larry Weisenthal/Huntington Beach, CA
You’re welcome, Larry. Doesn’t mean anything in reality, but if it makes you happy. Facts still remain… Reagan’s tax policies result in a steady incline in revenue during a recession, and Clinton’s tax increases on the individual resulted in a declining revenue trend.
But you cling to your “sky is blue” simplicity. Not to put a damper on your spirits, I didn’t say “tax cuts don’t pay for themselves”. I said the obvious… the government collects less revenue.
@Nan. Besides getting rid of ObamaCare, you could also get rid of Medicare and then you’d “save” 77 gadzillion dollars in taxes. But, guess what, all those people would still need health care and someone would have to pay for it and it would cost MORE THAN 77 gadzillion dollars.
You could also get rid of the police department and “save” a bunch of tax dollars. But then everyone would have to go out and buy Glocks and dobermans and hire bodyguards.
The question is this: does the private sector do a better job or a worse job, in a given area? Market economics doesn’t work in health care because the “sellers” (doctors) make virtually all of the big ticket purchase decisions for the “buyers” (patients).
– Larry Weisenthal/Huntington Beach, CA