Death Panels – American Style

By Greg Scandlen

The new Medicare benefit for end-of-life counseling that was snuck in by the Obama Administration over the objections of Congress and the American people, is the fourth and final step of a process that will indeed lead to “death panels.”

Now, don’t misunderstand. You will not go before a panel of bureaucrats to plead for your life. That was Franz Kafka’s early twentieth century Bohemia. We are much more sophisticated today. In twenty-first century America, your sentence will be delivered by your friendly family doctor.

STEP ONE — We started two years ago with the appropriation of $20 billion to set up a mandatory Health Information Technology (HIT) system. This was part of the wonderful “stimulus” bill that was enacted well before ObamaCare. This law requires every physician’s office and every hospital to be wired up to a centralized database, so the government may know exactly what each doctor is doing with every single patient.

All of the research available says that HIT does not improve care or lower costs. Quite the opposite — it worsens care and raises costs. What it does do is enable the government to know with precision what a doctor is doing.

STEP TWO — The next step was also funded in the stimulus bill – the “Comparative Effectiveness Research” (CER) initiative. This will allow a panel of experts to determine what works and what doesn’t work in medical treatment. By “work,” they mean what is the best use of the available dollars. If something is quite expensive and doesn’t prolong life by many months, it will be deemed to “not work.”

That might be useful knowledge to have for a physician who is looking at treatment options. It could be one more piece of information in his understanding of what to do for a patient. But it becomes a problem only once the next step is implemented.

STEP THREE – Now we get to ObamaCare, and the presumption that the best (only?) way to finance health care is through “Accountable Care Organizations” (ACOs), that pay physicians on a “Pay-For-Performance” (P4P) basis. P4P says that doctors will get paid more when they do the “right thing,” and less when they do the “wrong thing.”

Now we’ve got something. Now we have HIT telling the government what every doctor is doing, and we’ve got CER determining what is the right and what is the wrong thing to do, AND now we have a payment system that will “incentivize” doctors to do what the government says. There is only one thing missing – how to tell the patient.

STEP FOUR – “End-of-Life Counseling.” There is no acronym for this as yet. End-of-Life  Counseling will pay physicians to deliver the bad news to the patient — “I’m afraid your breast cancer is quite advanced and there isn’t anything further we can do. How can I help you get your affairs in order?” Now, notice the physician is not explaining there IS something that can be done, but the government decided to not pay for Avastin because it costs too much. Or any of the other life-enhancing treatments that would be available if not for federal intervention. No, Medicare would not pay the doctor to deliver this information because it might upset the patient.

So, there you have it. In twenty-first century America, our Death Panel is good old kindly Dr. Marcus Welby. Don’t you feel better already?

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Protocols versus Individualized Care

By Marcy Zwelling-Aamot, MD FACEP

We have started to see the downside of government interference in the patient/doctor relationship.  No surprise, it is not what doctors have warned their patients about.

Recently United HealthCare announced a new way to pay for cancer treatment —  “The new fee is meant to encourage doctors to follow standard treatments rather than opting too often for individualized and unproven courses of therapy.”  (New York Times, 10/19/2010).

Like every relationship, the patient/doctor relationship is complex.  But in medicine it is further complicated by a financial relationship that removes the patient from any decision making process. Third-party payers, particularly the government, distorts any opportunity to offer direct accountability and responsibility for our work.

The government payer system is predicated on a pot of money that must be divided among all doctors.  It is further complicated by political pressures.  In the end, doctors who do procedures have always been paid much better than those of us who only have our brain and time to sell.  Most private insurers follow the government when it comes to doctor payment.

Oncologists have never been paid for their consultative services.  To keep their offices open, they have had work directly with pharmaceutical companies to save their patients’ lives, keeping large inventories of drugs in their office at huge expense.  With this as background, medicine and genomics has advanced to the point where we can create individualized treatment strategies in cancer management that saves our patients’ lives.

Protocol management has dominated oncology therapy.  Cancer therapy is so risky, protocols move slowly to prove themselves successful. But, our thinking about cancer management has changed with the evolution of genomics.  We have proven that some patients are not genetically able to metabolize certain therapies. Now individual patient management dominates the discussion and lives are being saved.  No sense in wasting time and money on treatment that brings only risk for a specific individual patient.  This is a huge advancement.

Now, insurers, in order to save money, are asking my colleagues to participate in nothing short of blackmail.  An oncologist may get paid a bonus to ONLY use the protocol management rather than individual treatment strategies when treating patients with cancer.  No one anticipated things would disintegrate so far so fast after the passage of “ObamaCare.”  Who could dream up such a nightmare?

No, there are no death panels.  And, technically, the government has not mandated that patients not see “their” doctor of choice.  Rather, they have subversively applied blackmail to the marketplace of life and death.

The difficulties that result from a patient/doctor relationship that is complicated with third-party payers are the root of many of the distortions that add cost and a “dys” use of our limited resources in the U.S. healthcare delivery system.  This subversive interference with complicated life and death decisions demonstrates the immediate need to repeal ObamaCare in order make the right reforms.

The first reforms need to be about solidifying what is best about the delivery of health care in any system and that is an uncompromising trust in our relationship with our patient.