Obama's End-of-Life Agenda

Let them eat painkillers!


Do you know your DNR status? You should. So why are Obama & Co. sneaking around behind your back get your doctor to bring it up?

Background:

To reduce the controversy surrounding the Democrats' health care legislation, section 1233 was removed. Section 1233 would have provided for financial compensation for end-of-life counseling. According to the New York Times, Section 1233 is making a comeback via Obama's bureaucratic machine:
Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.

Congressional supporters of the new policy, though pleased, have kept quiet. They fear provoking another furor like the one in 2009 when Republicans seized on the idea of end-of-life counseling to argue that the Democrats’ bill would allow the government to cut off care for the critically ill.
The full text of Section 1233 is here.

By default, you get a "full code" if you haven't specified otherwise. That means that in an emergency, anything that can be done will be done. All aggressive, invasive and heroic options are on the table.

At the other end of the spectrum, a DNR (Do Not Resuscitate) order means that a patent does not want aggressive forms of life-saving intervention such as CPR, mechanical ventilation (life support) or defibrillation/cardioversion.

If you are of advanced age, or if you are in very poor health, you might prefer a DNR order ― and that's where end-of-life counseling is appropriate. You can talk with your physician (or under Obama's plan, a nurse or a physician's assistant) and sort the issues out in advance.

The complexities of a real-world medical emergency can render end-of-life plans or "advance care planning" perfectly useless, but a discussion with your physician on these issues can be very productive.

So why won't the Obama administration address this issue openly? Why hide behind a thousand layers of bureaucratic opacity? Perhaps it is because the implementation of Obama's end-of-life agenda raises some difficult questions:
  • Is compensation specifically for end-of-life counseling necessary? If so, why? Physicians can bill for general counseling already... Why is there a fierce urgency to single out this issue?
  • Will patients and their families be adequately educated on the reversibility of DNR orders?
  • Does the government have a conflict of interest in this matter? (Saving money with more DNR orders).

Where are the potential conflicts of interest?

It also appears to make this a voluntary conversation (at least for now), one the patient can decline without any repercussions.

There is, however, something at least vaguely disturbing about a government incentivizing doctors to [provide end-of-life counseling] as part of an expansive regulatory program that has, as one of its primary goals, cost reduction.
I would point out that the language of 1233 appears to be written to begin the process of making end-of-life counseling mandatory for physicians:
Physician's Quality Reporting Initiative...

...the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted... Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.
What is the Physician's Quality Reporting Initiative (PQRI)? Big brother explains:
The 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services...
For many physicians, because of the way these funds are filtered through hospitals, these "incentives" take on all the characteristics of a mandate. The coercive quality of this initiative is expected to increase over time.

Obama's end-of-life agenda turned out to be too controversial to implement under the glaring light of the legislative process, so it's being sneaked in through the murky channels of unchecked bureaucratic power. As usual, William Jacobson gets to the heart of the matter:
Procedurally, we all should care. This is a textbook example of what I have been warning. Obamacare simply is the infrastructure. The details and the demons will be worked out in regulations.

The fact that such a controversial change was kept quiet for so long, and that the Obama administration took steps to keep it quiet, is most troublesome of all.

Defunding is the only option at this point, because the regulators cannot be trusted.
Nibbling away at the edges of ObamaCare will never suffice. Repeal it!


Discussion: Memeorandum


Update:

Nick Rowe asks some important questions in the comments section. I think these questions deserve a front page answer:
As conservatives and libertarians, most of us want Medicare and Medicaid eliminated or, at least, curtailed. So why are we attacking Obama and the Demon Rats on the very rationing of health care that we ourselves would impose? Just because it is politically convenient at the moment?

As conservatives and libertarians we don't approve of central planning or bureaucratic restrictions on the consumption of goods and services. That's one of the many problems with so-called "death" panels, arbitrary quality of life scores, and other artificial rationing mechanisms.

Medicare resources should be allocated carefully. But as a proponent of free-market mechanisms, I would prefer to see those decisions made by individual health care consumers, rather than by politicians and bureaucrats. A Medicare voucher program could play a role in that.

Problems created by market distortions aren't solved by more market distortions. Providing government-financed incentives for physicians to prompt their patients to choose minimal end-of-life health care is just another market distortion that has the potential to create all kinds of moral hazards.

Physicians should receive compensation for any service that is valued by their patients, including counseling on any health care question. But is counseling on end-of-life care somehow more valuable to patients than counseling on any other issue?

Should patients and physicians be left alone to decide how their scarce time together will be spent, or do bureaucrats need to use carrots and sticks to get us moving in the right direction?

Should we blanket the population with end-of-life counseling, or should the advice and education be targeted? Should end-of-life counseling crowd out counseling on diet, exercise, tobacco cessation and proper use of medications... or should counseling on all these topics receive equal compensation?

How will these decisions be made?

If we ration time in the doctor's office based on incentives created by the Department of Health and Human services, will time be spent in the best interests of patients or in the best interests of Uncle Sam?

4 comments:

  1. Excellent overview of this disturbing government intrusion. I know with the elderly in my family, doctors have been open and truthful about the possibility of a good result with treatment or not. They haven't needed the government to give them a directive.

    I guess we know how this will be handled for the women with Stage IV breast cancer who can no longer get Avastin unless they are wealthy. The government's "advice" is fairly clear for these women - many of whom still have small children.

    I despise this administration.

    Hope everyone here had a Merry Christmas and a Happy Hannukah.

    ReplyDelete
  2. I find this square dance of political positions rather disturbing.

    As conservatives and libertarians, most of us want Medicare and Medicaid eliminated or, at least, curtailed. So why are we attacking Obama and the Demon Rats on the very rationing of health care that we ourselves would impose? Just because it is politically convenient at the moment?

    Health care is a private good produced with scarce resources. As such, it must be rationed. In a capitalist economy, we ration by price. Many of us have compassion for those who cannot pay, so we support either charitable donations or limited government support.

    But even when health care is completely private and paid for by insurance, then insurance companies can and SHOULD do the rationing. It's ridiculous to spend $1 million to keep someone alive for just a few more months, especially when we realize that those resources can and should be used on other people who would benefit more from them. We NEED death panels to tell people that it's a waste to spend good resources on them; in some cases even when they can pay.

    It is particularly disconcerting that we will "reward" people with urgent medical care after an entire lifetime of lifestyle choices which made them unhealthy in the first place.

    We can somewhat lower the cost of medical care by removing the artificial barriers to entry for doctors, nurses, medical equipment and prescription drugs. HOWEVER, when you increase supply in such a fashion, average quality will decline - at least in the short run. Perhaps those least able to pay deserve to have the doctors who graduated last in their class at medical school.

    Aside from rationing care, we're squeamish about forcing people to relinquish their assets, such as their houses, to pay for the end-of-life care. These dead-beats are pushing their medical costs onto others, claiming poverty, but holding on to valuable resources out of nostalgia.

    I know people from Roche, and they are quite upset about Avastin. Apparently the drug has some severe side-effects for breast cancer patients. I don't know how the FDA weighs the side-effect of "death" against all the others. But the drug might still be safe and effective for colo-rectal cancer, so it may be hanging around a while.

    ReplyDelete
  3. @Nick Rowe

    As conservatives and libertarians we don't approve of centralized restriction of consumption of goods and services. That's one of the many problems with Medicare and Medicaid, and that's one of the many problems with so-called "death" panels, arbitrary quality of life scores, and other artificial rationing mechanisms.

    As long as the program exists, Medicare resources should be allocated carefully. But as a proponent of free-market mechanisms, I would prefer to see those decisions made by individual health care consumers, rather than by politicians and bureaucrats. A Medicare voucher program could play a role in that.

    Problems created by market distortions aren't solved by more market distortions. Providing government-financed incentives for physicians to prompt their patients to choose minimal end-of-life health care is just another market distortion.

    ReplyDelete
  4. DNR's are already being used with and WITHOUT the consent of the elderly in this country to withhold life-saving interventions in both hospitals and nursing homes for the purpose of reducing costs. Don't be naive!

    Because citizens are living longer and the life span is extended every few years because of new technologies, the COSTS of treating the elderly at the end of their lives means that PUSH has come to SHOVE and DNR's are the only cost- saving measure available to reduce the growing costs of end-of-life care for elderly citizens on government programs (that are supplemented by profit-making private insurers).

    Nothing wrong with a DNR if there is INFORMED and EDUCATED consent and agreement between the Doctor and the patient as to what this will mean for the patient. Nothing wrong with a DNR as long as the elderly patient has the constituional right to rescind it.

    Maybe better to have all of this out on the table under a bright light! Maybe it is better to admit the "market distortion" and the "market forces" at work already in order to make the nation's hospitals safer places for the elderly citizens of this country.

    ReplyDelete

Commenting here is a privilege, not a right. Comments that contain cursing or insults and those failing to add to the discussion will be summarily deleted.