The New End-of-Life Counseling Benefit

By Greg Scandlen

The New York Times article by Robert Pear (who, by the way, is the best health care writer in the nation, notwithstanding his employer) that alerted the world to the latest sneaky Obama deal, said the following —

“Advance care planning improves end-of-life care and patient and family satisfaction and reduces stress, anxiety and depression in surviving relatives,” the administration said in the preamble to the Medicare regulation, quoting research published this year in the British Medical Journal.

Well, let’s take a look at that research. As the Times reports, it was published in the British Medical Journal. It is all of one – ONE – study conducted in Australia at one – ONE – location and involved patients that were aged 80 or older. Twenty-nine patients (that is – 29) got the intervention and another 27 were a control group (no intervention), and all 56 patients died within six months. The people who got the intervention and their families were more satisfied with the care and had their wishes followed better than the control group.

But that isn’t saying much. These folks got more attention in the last six months of life, so of course they were more satisfied. And they were asked what their wishes were, so of course those preferences were more likely to be followed. Decent research would have tested the particular intervention against a “placebo,” not against no intervention at all.

That is how drug trials are conducted. One group gets the drug being tested and the other group gets a placebo. The placebo group usually does better, too, but not as well as the test group. Honest research would have given each group the same amount of attention, but provided a particular set of interventions to one but not the other.

This research in no way supports providing everyone on Medicare with annual “advance planning counseling.” Most people on Medicare are relatively healthy and their wishes at age 65 may be far different than at six months before their death.

The Australian research was also notable for all of the things it left out. No one asked the patients if they had a will, for instance. There was no mention of assigning a durable power of attorney to anyone. In fact, there were no legal or estate issues involved whatsoever.

Even more shocking is that there was no mention of clergy involvement and the patients were not even asked about their religious affiliation. There were no hospital chaplains involved, no prayers, no last rites for Catholics, no discussion of funeral arrangements.

How can you have end-of-life counseling without dealing with these critical issues?

More importantly, how can Obama’s little Czars and Czarinas use the experience of 56 patients at a single hospital in Australia as a justification for a new benefit for 45 million Americans? And a benefit that has already been considered and rejected by the Congress of the United States?

If this is what is considered “evidence-based decision making” by this administration, we are in deeper trouble than I realized.

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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?

Why So Sneaky?

By Greg Scandlen

Two recent articles, one in the Washington Post about the new high-risk pools, and the other in the New York Times about the new end-of-life counseling, give plenty of material for discussion. They are on very different topics, but they both reveal something that should disturb all Americans. That is how very sneaky our political leaders have become.

The Post article notes that enrollment in risk pools is well below what was projected by the Administration just a few months ago. It was predicted by HHS that 375,000 people would have enrolled by the end of this year, but in fact, only 8,000 had actually enrolled by early November. The reporter asked HHS for updated figures, but, “HHS officials declined to provide an update, although they collect such figures monthly, because they have decided to report them on a quarterly basis.”  So, HHS has the numbers but won’t release them because they are embarrassing.

The Times article is even worse. To refresh your memory, a new end-of-life counseling benefit in Medicare was considered and rejected by Congress because of concern about “death panels.” It would have paid for such a session with your doctor once every five years.

Now, it turns out that HHS has, by regulation, decided to include it as part of a beneficiary’s annual “wellness” exam. So, rather than every five years it will now be yearly. Actually, it is not these counseling sessions that raise the concern about death panels, but the combination of the new “comparative effectiveness” standards of physician practice along with “pay-for-performance” incentives.

But, leaving that aside, what is shocking about the Times article is the revelation that the Administration and senior members of Congress purposely tried to hide the new regulation from the public. Robert Pear writes:

After learning of the administration’s decision, Mr. Blumenauer’s (The Democratic Representative from Oregon who sponsored the original proposal last year) office celebrated “a quiet victory,” but urged supporters not to crow about it.

“While we are very happy with the result, we won’t be shouting it from the rooftops because we aren’t out of the woods yet,” Mr. Blumenauer’s office said in an e-mail in early November to people working with him on the issue. “This regulation could be modified or reversed, especially if Republican leaders try to use this small provision to perpetuate the ‘death panel’ myth.”

Moreover, the e-mail said: “We would ask that you not broadcast this accomplishment out to any of your lists, even if they are ‘supporters’ — e-mails can too easily be forwarded.”

The e-mail continued: “Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch and may be calling on you if we need a rapid, targeted response. The longer this goes unnoticed, the better our chances of keeping it.”

So here is a new benefit for Medicare that the elected representatives of the people don’t want the press to “discover” for fear that the people may object to it.

On top of the secret recess appointment of Dr. Don Berwick to head CMS, this government is looking more like the Hugo Chavez regime every day.