End of Life Counciling-- The Same as "Death Panels"?
New Medicare regulations allow for annual “end-of-life” counseling as part of the annual wellness check-up covered by Medicare as of January 1, 2011. This end-of-life counseling, covered in Section 1233 of the Healthcare Reform Bill passed by the House, but not included in the final bill signed into law by President Obama, is the section of the Healthcare Reform Bill dubbed ‘Death Panels’ by opponents of the bill. Since most Americans still indicate that they oppose the Healthcare Reform Bill, writing this provision into the new regulations, rather than include it in the bill, is an attempt to circumvent the political process, and the will of the people. Politics aside, what are the ramifications of this regulation to the Medicare Provider?
Let’s look at this issue coolly and rationally, avoiding all the rhetoric that seems to be pervasive throughout any discussion on healthcare reform. There is absolutely nothing inherently wrong with providing elderly patients with all the information on treatment choices available to them. I, for one, would like to have every available piece of information possible in order to make the best possible decision for my healthcare. Denying this information to anyone seems unwise, at best, and unethical at worst.
Ethical doctors, which comprise the vast majority of doctors, already provide their patients with the information they need to make their own healthcare decisions. Paying these doctors for a service that they already provide should not change the information that these doctors provide. The concern, and it is legitimate concern, is that there will be pressure placed on Medicare doctors to recommend less expensive treatment options when healthcare becomes rationed. And make no mistake; healthcare will become rationed through the healthcare reform bill. Of course, healthcare is already rationed, though now it is rationed by price, and through the healthcare reform bill it will be rationed by government.
A little time needs to be spent on healthcare economics. Since my undergraduate days, I have heard that 80% of all medical costs are incurred in the last 6 months of life. Not taking this figure at face value; a quick web search found that according to the Canadian Institute of Actuaries, through “the Romanow commission on the future of health care, the institute said that 30 to 50 per cent of total lifetime healthcare expenditures occur in the last six months of life.”
A study conducted by Donald R. Hoover PHD, et al; entitled: “Medical Expenditures during the Last Year of Life: Findings from the 1992–1996 Medicare Current Beneficiary Survey” concluded that the mean annual expenditure in the last year of life “for persons aged 65 and older were $37,581 during the last year of life versus $7,365 for non-terminal years. Mean total last-year-of-life expenditures did not differ greatly by age at death.” And that “last-year-of-life expenses constituted 26 percent of Medicare, and 25 percent of Medicaid expenditures.”
Even if we use the lower number of 30% of healthcare costs in the last six months of life, that would equate to $720 billion in America Clearly, a lot of money is spent on prolonging the life of people another 6-12 months. I am not advocating that this money should not be spent on individuals to prolong their life. What I am saying is that people should be allowed to make this important decision based on accurate information provided to them. Some people may decide that they would rather leave the money to their heirs, or to a charity; knowing that they may forego 6-12 months of life. Other patients may decide that they wish to remain on earth as long as possible, regardless of the cost. Either way is fine as long they have the proper information to make the choice themselves (or with their family), and not have the decision made by some governmental bureaucrat.
That is the fear that many opponents of the healthcare reform bill have: more governmental control over individual healthcare choices. Government officials, only looking at the bottom line may decide which treatment(s) will be allowed for terminal patients. President Obama admitted this position in a Q&A session during the healthcare debate in 2009.
Even ethical doctors who want the best for their patients may bow to pressure from Medicare and Medicaid officials. When the majority of their income is derived from governmental sources, and the government instructs them to recommend less costly treatment or to forego treatment all together, some doctors will take the path of least resistance.. Remember the ‘good old days’ of HMO’s.
The government will have the power, through licensing and taxing powers to ‘urge’ doctors to provide information to their patients on ‘proper’ end of life choices. The Romanow commission, though noting the sensitivity of the subject, suggested greater use of less expensive palliative care and living wills.
Though I have faith that individual doctors, in private practice, will continue to do the right thing when it comes to their patient’s care, the future will make it increasingly difficult for them to do so. I’m just trying to provide a warning of what may be coming down the pike for healthcare professionals in the future.
And then I become aware of the following item, published in the NY Times on January 4, 2011:
WASHINGTON — The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday. The move is an abrupt shift; coming just days after the new policy took effect on Jan. 1. An administration official, authorized by the White House to explain the mix-up, said Tuesday, “We realize that this should have been included in the proposed rule, so more people could have commented on it specifically.” “We will amend the regulation to take out voluntary advance care planning,” the official said. “This should not affect beneficiaries’ ability to have these voluntary conversations with their doctors.”
Obviously, the government still wants end-of-life counseling to be included in Medicare regulations, but this has been tabled for the time being. Let’s see what happens in the future. In any case, this issue will come up for debate in the future, and my position is the same: End-of-life decision should be left up to the patient (or family) and their doctor, not a government official.
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#1 by Steve Rolfe on January 19th, 2011
You conclusion does not follow from any of the points you made in the article above. End of life counseling is a doctor and patient discussion, nothing more. The government proposes no role in this other than to pay for a doctor’s time to have that discussion. While saving money on healthcare may be a desirable benefit from such a discussion it is far from the most important. Giving the patient and their family complete information about end of life issues allows them to chose how to manage those issues. The alternative is that someone else will make those choices which is far less desirable.
The fact is many people who receive expensive end of life care don’t have their life extended at all. The extra care in the form of invasive tests and surgeries are painful and life degrading. They are much sicker in those last weeks or months. They are unable to spend quality time with their loved ones. And, they die just the same. We must all be reminded that everyone of us will die sometime. At some point either from extreme illness, severe accidents, or just plain old age we will die no matter how much healthcare we receive regardless of how much money we spend.
#2 by J. Dawson, D.O. on January 20th, 2011
Many thanks for the great article on “end of life counseling”; very well-written and now I have a better idea of why the whole idea of pressuring patients like this is so unprofessional! Thank you….
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