The Pre-Election Edition of Health Wonk Review: Fact vs. Fiction

 This week I am delighted to be hosting the pre-election edition of Health Wonk Review,  a bi-weekly compendium of some of the best healthcare posts of the past two weeks.

Below, a summary of posts tackling issues voters will be thinking about as they go to the polls.

Before you vote, get the facts:

- As President, would Mitt Romney protect  people suffering from “pre-conditions” and make sure that they could get insurance?

– Could Romney dismantle health care reform, as he has promised?

– Some people say women won’t and shouldn’t vote for Romney. Are they right?

– Can we really afford to insure an additional 30 million Americans?

–  What will happen to our Academic Medical Centers?

– What about the individual mandate: will it really “save lives”?

– What will “Comparative Effectiveness” research mean for patients?

–  If we add 30 million newly insured Americans to our health care system, will I be able to find a seat in my doctor’s’ waiting room? Will ERs be even more crowded?

– Why are gubernatorial candidates saying so little about Medicaid Expansion?

–  Is anyone still worried about “Death Panels”?

– If Romney is elected, wiil reform continue on the ground? ]

– Bonus for those just plain tired of the election, and who worry about what is happening outside of the U.S:  “Sugar Isn’t just killing us; it is killing those who harvest it for us.”

Below, I have tried to use sub-heads so that readers can focus on the issues that most interest (or worry) them, without reading every word of the post.

Romney & Pre-Conditions

On Managed Care Matters, Joe Paduda addresses the telling differences between the Affordable Care Act and Governor Romney’s version of reform in a post titled “What Parts of Obamacare Do You Want to Keep? Eliminate?” 

Governor Romney has said that, if elected, insurers will not be allowed to deny you coverage because you suffer from a “pre-condition.” But Romney doesn’t believe in “price regulation,” and as Paduda points out, this means he won’t insist that insurers sell a policy to a sick person at “list price.”

If you’re suffering from a pre-condition your policy could cost you “two, three, even five times more,” Paduda explains. In other words, you probably wouldn’t be able to afford it.

Also, under Romney’s proposal, you would have to have “continuous coverage, moving directly from one plan to another. For Americans who haven’t had coverage for a few months, you’re out of luck.”

As to what parts of the legislation you want to keep or eliminate, Paduda observes that “The reality is there’s a lot to like about Obamacare, as Romney has found—otherwise, he wouldn’t be backpedaling on his earlier promise to kill the whole thing. Moreover, despite what Romney has said in the past, “the practical reality is the he can’t overturn the PPACA . . . unless he gets 60 senators to agree with him.

“In sum the ‘Affordable Care Act’ is the law of the land and can’t/won’t” be repealed, Paduda concludes, “despite Romney’s occasional statement to the contrary.”

Could Romney Over-Turn Reform Legislation?

Writing on healthinsurance.org I also looked at the question of whether Romney could dismantle reform, interviewing Washington & Lee law professor Timothy Jost, who specializes in healthcare law.  He confirms that even if Republicans take the White House and win a majority in the Senate, Romney wouldn’t have the power to “repeal the full legislation.” We live in a nation ruled by law, not magic wands.

Republicans would need a three-fifths majority (60 votes) in the Senate. They now have just 47, and Jost notes, “nobody thinks Republicans will get 60 seats.”  

Romney also has said that he will issue “Obamcare waivers to all 50 states” that would let them ignore the Affordable Care Act. But Jost observes, “there are no ‘Obamacare  waivers’ that could be issued by executive order.”

That’s right: these waivers simply don’t exist. Here, we’re tripping over one of those “Big Lies” that have become a feature of the Romney campaign.

When Congress reconciles the budget, it could do some damage to Obamacare by nixing the premium subsidies and the individual mandate, says Jost  But budget reconciiation often takes 4 or 5 months and legislators can only revise laws that affect government revenues and spending.

Congress would not be able to change the new regulations for insurers, who still would be required to cover everyone, regardless of pre-existing conditions. Yet without a mandate or subsidies, most of their new customers would be people suffering from serious pre-existing conditions. This would create “quite a mess” Jost observes, driving up premiums for everyone.

Romney and Women

Posting on healthinsurance.org earlier this month, Linda Bergthold writes: “The Governor was scheduled to appear on ABC’s ‘The View’ yesterday, but cancelled and sent his wife instead. His cancellation shouldn’t be a shock to anyone, since Romney has commented about the five women co-hosts that ‘four are sharp tongued’ and ‘only one is a conservative.’”

“Sharp-tongued”–as in “shrew”? If they were men, would they be praised for their “acerbic wit?”

But Bergthold doesn’t belabor Romney’s choice of words. She is more concerned that “he changes his mind on women’s issues with “dizzying frequency.”

“Given the contradictory views and statements he has made about women,” she writes,  ”it is not surprising that he would avoid being interviewed by women who might well challenge him.”

Certainly he has every right to change his mind, she acknowledges, “although his reasons are usually related to his political career. Early in that career, as he sought office in Massachusetts, he sounded almost liberal on women’s issues,” she continues. “He spoke at a Planned Parenthood event and his wife donated to Planned Parenthood. He endorsed the legalization of RU-486 the abortion-inducing drug.” This made him popular in Massachusetts.

But once he became the Republican Party’s presidential candidate, another Romney emerged:  “Not more than a few months ago,” Bergthold points out, “he said he supported the Blunt Amendment which explicitly allows employers to deny their women employees coverage of services such as contraception. Where he used to support Planned Parenthood, he now  . . . has promised he would eliminate it. In the second Presidential debate, he refused to take a stand on fair pay for women.”

When Bergthold points out that Romney’s flip-flops “usually are related to his political career,” she makes a sobering point: Imagine Mitt Romney ensconced in the White House, surrounded by  Republican colleagues in Congress urging him to establish his legacy by re-making America (taking us back to the 1950s). Just how far to the right would he move?

Bergthold warns: “On abortion Romney has taken almost every position possible. When he ran for the Senate from Massachusetts he said he was firmly pro-choice. In the Republican primaries this past year, he said he was firmly pro-life. He has said he would like the Supreme Court to overturn Roe v. Wade and return the decision to the States. (And if Roe v. Wade were overturned tomorrow, it is estimated that at least half the states would outright ban abortion within the first year.)

“As President, Romney would likely have at least one if not two appointments to the Supreme Court, and only one is needed to overturn Roe.

At the end of her post, Bergthold asks some compelling questions:  “With these anti-women views, why has Romney seemingly wiped out  the substantial gender gap between him and Obama in the last few weeks? Why in the world is Romney closing in on Obama with women in major polls? Do women know what is at stake for them?”]

Over on Health Access.org Linda Leu is just as alarmed. In a post titled “Binders Full of Women, But What About Their Health?” she begins with equal pay for women, and documents how Romney and his campaign have gone back and forth on this issue,

She then points out that the Romney ticket has repeatedly promised to repeal Obamacare “you know, that little law that made being a women is no longer a pre-existing condition.  “The Affordable Care Act forbids discrimination based on gender (both denials and higher prices), and requires that insurers cover all of women’s essential health needs – including reproductive health care and maternity care.”

 Even if Romney cannot overturn the law, his lack of concern about what women would lose is troubling.

Meanwhile, Romney has pledged that he would eliminate funding for Planned Parenthood “despite the fact that are millions of women all across the country rely on it . . . for mammograms, for cervical cancer screenings . . . and 6 out of 10 Planned Parenthood clients use it as their primary source of health care.”  

On abortion, Leu reports that “As Governor of Massachusetts, Romney vetoed legislation giving rape survivors access to emergency contraception.”  Meanwhile, in Congress, Paul Ryan, Romney’s running mate, “helped defeat a measure that would have eased restrictions on abortion access for military women who are raped.”

Wait a minute. If a women is in the military, and is raped (whether by a civilian or a fellow officer), she can’t have an abortion—even though our laws says that abortion is legal? Is that where this country is headed?

 Readers: Let me suggest, if any  of the women in your families are on the fence, send them Bergthold’s and Leu’s posts. Every woman should have the facts, and decide for herself.

Can We Afford Health Care Reform?

On the Disease Management Care Blog, Dr. Jaan Sidorov begins by drawing a parallel between public transportation and health care reform: “Did you know that the taxpayer costs of some versions of public transportation have proven so expensive that it would have been cheaper to provide each rider with their own BMW?” he asks.

He then explains that this ”is why the Disease Management Care Blog, which always uses public transportation in and out of the SFO, ORD, ATL, PHL airports, ascertained that it was time for it to make its coupe selection. Unknown to the DMCB spouse, it has started to examine the trade-offs between bimmer cost, speed and comfort.”

From a libertarian point of view, I guess the parallel makes sense: If someone thinks public transportation is a bad idea, it wouldn’t be too surprising if he also believed that “universal coverage” is an extravagant notion. After all, it’s another one of those “collective” ideas.

But  even if Sidorov is drawing the analogy tongue-in-cheek, he is quite serious about the cost of heatlh care reform. Citing “conservative-leaning Gail Wilensky’s recent aricle in the New England Journal of Medicineof Medicine.” he notes that, under Obamacare, “Affordability and quality remain serious challenges.”

He elaborates: “That’s because, despite some promising (but ultimately still unproven) innovations involving bundled payments and shared risk, Obamacare leaves Medicare’s fee-for service reimbursement very much intact for years to come. That means  . . healthcare costs will take a greater and greater share of America’s gross domestic product.” 

He continues: “The much ballyhooed value-based payment bonuses are quite modest and” in his view, “unlikely to significantly alter hospitals’ approach to doing business.”

Meanwhile, “Congress’ past vulnerability to special interests and the low likelihood that the Independent Payment Advisory Board (IPAB) will change physician behavior does not inspire confidence.”

In that last comment Sidorov ignores the fact that if Congress wants to overrule the IPAB, it would have to come up with a proposal to save an equal amount of money without either undermining the quality of care, or rationing care. This could be extremely difficult.

But it is unlikely that  the IPAB will be needed. Under the Affordable Care Act, the Secretary of Health and Human Services has the power to squeeze waste out of Medicare by lowering payments for services that seem “overvalued,” while lifting payments for “undervalued services,” without going through Congress.

To his credit, Sidorov remains open-minded: he is not entirely convinced by what he calls his “depressing” argument. At the end of his post, he acknowledges: “An accurate portrayal of bad times to come? Maybe . . . Maybe Not.”  

No one can predict the future, but I have addressed some of Sidorov’s concerns in two recent posts on HealthBeat, pointing to facts that might cheer him up.  

 First, consider Sidorov’s  fears that, under reform, healthcare “will take a greater and greater share of America’s gross domestic product.”

In “Truth Squad: Is Obamacare Pushing Health Care Spending Higher? What Will Happen in 2014?” I cite a recent report from the Office of Management and Budget. It suggests hat “when Obamacare kicks in, federal outlays for health care, as a percentage of GDP, are projected to rise only slightly from 6.4% of GDP in 2011 to 6.7% in 2014 and 2015.”

 “And this is just a guesstimate,” I add. “Recent trends suggest that Medicare spending already has begun to slow . .   By 2015, government spending for healthcare may equal less than 6.7% of GDP

 According to Peter Orszag, the former head OMB, since reform legislation passed in 2010, “the U.S. continues to experience a very marked slowdown in the growth of health-care costs. National health expenditures rose just 3.8 percent from August 2011 to August 2012.”

Meanwhile, “Medicare spending increased by only 3.2 percent in the fiscal year ending in September 2012.  These are remarkably low growth rates,” Orszag writes. “Consider that over the past four decades Medicare spending increased by more than 10 percent a year.”

Looking ahead,  “in January 2009, the Centers of Medicare and Medicare projected that expenditures would reach 19.8 percent of gross domestic product in 2017. This year, the projection for 2017 is down to 18.4 percent of GDP. That difference amounts to a whopping $280 billion.”

Why is healthcare inflation slowing? Orszag and others argue health care providers are anticipating changes in how both Medicare and insurers will pay for care under health care reform. They know that instead of being paid for volume (fee for service) they will be paid for value (better outcomes at a lower price) and so they are striving to become more efficient.

In a second post, titled “Breakfast With Atul Gawande” I give an example. Gawande’s Boston hospital already has agreed to contracts with insurers that will reward qualty– and penalize inefficiency. “if the hospital exceeds its cost-reduction and quality-improvement targets it will share in the insurers’ savings,” he explains. But “if it misses the targets, it will lose tens of millions of dollars.” 

Here is the answer to Sidorov’s concern that the “value-based bonuses are too modest to affect how hospital’s do business.”  Both Medicare and insurers will be using sticks as well as carrots to encourage hospitals to provide less expensive, better co-ordindated, safer care.

And Gawande’s hospital is not unique. Orszag reports that “recently the Health Management Academy of industry leaders conducted a survey asking chief executives of health- care systems: What share of your revenue in 2020 will be derived from payment schemes other than fee-for-service? The average response: 62 percent.”

Academic Medical Centers

Some teaching hospitals are worried about the changes. On Wing of Zock, Doctors Joanne Conroy, and Coleen Kivlahan write about the : “Impact of New Payment Methodologies on Support for Graduate Medical Education.”

They begin by noting that “Many of our nation’s academic medical centers (AMCs) are experimenting with care redesign by participating in risk-based payment strategies: ACOs(Accountable Care Organizations), bundled payments, and capitated payments” which ask hospitals to participate in the risk associated with medical care. If they manage to achieve better outcomes at a lower price, they share in the savings. If they fail, they lose money.

Conroy and Kivlahan are concerned that current methods for calculating these payments do not take into account the fact that teaching hospitals need larger reimbursements in order to cover the costs of educating medical students while also caring for patients.  In particular they worry about the fact that reformers are focusing on “decreasing unnecessary readmissions.”

The note that if  hospitals do a better job of preparing patients for discharge so that they don’t “bounce back,” Academic Medical Centers will “ lose the patient care and medical education payments associated with those (additional) hospital stays, although educational and mission-related costs remain.”

Oddly, the authors seem to gnore the fact that patients are better off if they don’t have to be readmitted. Patients, after all, are supposed to be at the center of reform.

True, academic medical centers will lose revenues, but under reform, they, like other hospitals, are expected to make up the difference by squeezing some of the waste out of their systems while  training doctors, nurses and students to work together,  more efficiently, in teams.

We have ample evidence from the Dartmouth research that at some of our finest academic medical centers– just as at other hospitals–up to 25% of our Medicare dollars are wasted on redundant tests, and unnecessary treatments.  Meanwhile, Dartmouth’s researchers note, some of the least expensive, “most effective” forms of care “(such as the use of beta-blockers for people who have had heart attacks and screening of diabetics for early signs of retinal disease)’” are “under-used,  even in hospitals considered among the ‘best’ in the country – including some academic medical centers. The causes of underuse include discontinuity of care (which tends to grow worse when more physicians are involved in the patient’s care) and the lack of systems that would facilitate the appropriate use of these services.”

 Finally, Conroy and Kivlahan argue that if AMC’s r revenues are pared, they won’t be able to continue to care for the poor. Here they overlook the fact that under reform, Medicaid will be expanded, and low-income families will receive premium subsidies. As a result some 30 million Americans will have insurance, and academic medical centers will no longer have to absorb the cost of their care.

Individual Mandates

On Colorado Health Insurance Insider Louise Norris makes the case for individual mandates in a  post titled “Individual Health Insurance Mandate from a Perspective of Compassion” She opens her post by by noting that “We expect people to take personal responsibility for a lot of things, and maintaining health insurance coverage is one of those things. But without an individual health insurance mandate that requires people to do so, there’s a not-insignificant portion of the population who will choose to forego health insurance.  Maybe they could afford the premiums if they scrimped and saved or prioritized their spending differently, but for whatever reason, they don’t.  

“It’s easy to say that they need to take responsibility for their situation if they then find themselves in need of expensive care and unable to get affordable health insurance because of a pre-existing condition.  But in the words of Pulitzer Prize winning writer Nicholas D. Kristof, this ‘seems ineffably harsh.’”  

Norris points to a recent NY Times op-ed  where  Kristoff wrote about a friend who is battling advanced prostate cancer.  “Kristoff’s Harvard-educated friend quit his job in 2003 and has been uninsured ever since.  He’s done seasonal work preparing tax returns for the last several years, but . . . was loathe to  purchase coverage in the individual market because of the cost.  Last year, he started having difficulty urinating and saw blood in his urine . .  .  His cancer was diagnosed when he was sick enough to need emergency room care. . . Kristof and his friend Scott are quick to admit that Scott “screwed up catastrophically and may die as a result.’”

Scott: “knew the risks and chose to live without health insurance anyway,” Norris writes “But Kristof points out that a mandate requiring everyone to carry health insurance is a safety net that helps to keep mistakes from turning into catastrophes.  He sums it up perfectly with this:

‘We all make mistakes, and a humane government tries to compensate for our misjudgments. That’s why highways have guardrails, why drivers must wear seat belts, why police officers pull over speeders, why we have fire codes. In other modern countries, Scott would have been insured, and his cancer would have been much more likely to be detected in time for effective treatment.

‘Is that a nanny state? No, it’s a civilized one.’”

On NCPA John Goodman offers a very different take on the same story. In “How Not to Think about Healthcare”  he writes: “Although Kirstof  describes his friend as ‘a victim in part of a broken health care system,’ nothing could be further from the truth. [Scott] Androes was a middle class professional who decided not to buy health insurance because it was too expensive. As he developed symptoms, he chose not to see doctors and to avoid other expenses in order to save money. By the time he chose to seek care, he was in critical condition.

“ Kristof believes that ObamaCare would have prevented the tragedy . .  If the new law had been in place.  . . Androes cancer would have been caught earlier and his survival chances would have been greater if everyone were forced to have health insurance.”  

“He’s wrong,” says Goodman.  “ObamaCare doesn’t force everyone to have health insurance. The penalty for being uninsured is small, relative to the cost of the insurance. There is very little the IRS can do to enforce it.”

Surprisingly, Goodman ignores compelling  evidence that even whenpenalties are low, mandates work: Massachusetts.

n the Commonwealthy 98.1% of adults and 99.8% of children now have medical insurance.  And the penalty that the state’s citizens would have to pay if they didn’t purchase insurance is far from Draconian: For 2012, the highest penalty works out to be $105 a month, or $1,260 a year—far less than the cost of insurance. The mandate succeeded not because the penalty was so high but because the majority of us generally comply with the law—particularly if we will wind up paying a fine if we ignore it.  Once seat belts became mandatory, more and more Americans buckled up.

Yes, the citizens of Masschusetts are more affluent than the citizens of many states. But under Obamacare, low-income and middle-income families will receive generous subsidies, makiing it far easier to afford insurance.

By contrast Goodman’s solution is to give everyone a $2500 voucher to buy insurance. If they don’t do it, slap them with a $2500 fine. Of course, $2500 won’t buy much coverage  (in the individual market, a comprehensive policy that covers one person now runs $5500 to $6000 dollars), and Goodman does not recommend subsidies to help people pay the premiums.

Given the heavy fine, if Goodman’s proposal became law, presumably most Americans would take the $2500 and buy some sort of bare-bones policy. Probably it would come with a high deductible. Since median-income and low-income famlies wouldn’t be able to afford the deductible, they would use the insurance only for catastrophic care. Insurance company revenues would rise, but Americans would not get the comprehensive ongoing care that they need.

Goodman ends his post: “In his Thursday column Kristof announced that his friend Scott Androes had passed away. The new column repeats almost every error that was in the original column.  . . . . Then he gets emotional with this:

‘To err is human, but so is to forgive. Living in a community means being interconnected in myriad ways — including by empathy. To feel undiminished by the deaths of those around us isn’t heroic Ayn Rand individualism. It’s sociopathic. Compassion isn’t a sign of weakness, but of civilization.’”

Does this strike you as overly emotional? As Goodman says, “I report. You decide.”

What will “Compative Effectiveness Research” Mean For Patients? 

Many patients are worried that  the “comparatie effectiness research” that is funded by reform legislation will mean that they won’t get the care that their doctor says they need. They worry that the  research– done by scientists who have never cared for a human being– will conclude that the treatment their doctor recommends won’t be any more ”effective” than another, less expensive stategy.

This post, from Health Affairs Blog, might reassure some patients.   In Getting Specific: Selecting Patient- And Stakeholder-Initiated Topics,” the Patient-Centered Outcomes Research Institute’s (PCORI’s) Joe Selby and Rachael Fleurence describe  the two paths that PCORI is using when choosing which comparative effectiveness research to fund: : “an investigator-initiated path  (calling on the research community to submit proposals) . and a “patient- and stakeholder-initiated path” (whih involves reaching out to the community to solicit questions.)

The second path is time-consuming, they say, but : ‘We recognize that our investigator-initiated process, even with the collaboration of stakeholders, could miss important questions that matter to patients.  . .  This approach has the advantage of allowing us to focus dedicated or additional resources on areas identified as high priority . . . Patients and other stakeholders need to feel a sense of ownership of the research process.”

 Will I Be Able to Find a Seat in My Doctor’s Waiting Room?

Gloomsters predict that when 30 million Americans are added to our health care system, ERs will be overflowing, and you may find that you can’t get an appointment with your own doctor. Others suggest that as demand for medical care rises, so will prices.

On healthinsurance.org I recently published a post headlined  ”Fear of crowded doctors’ offices unwarranted”  based on a  report that Price Waterhouse Cooper’s  (PWC’s) Health Research Institute  (HRI). issued earlier this month.

According to PWC,.the fear-mongering is just plain wrong. 

The number-crunchers at PWC point to demographic data that suggests the newly insured are not likely to “overwhelm the healthcare system or substantially drive up costs immediately after gaining coverage.” This is because: “he overwhelming majority – 88% – will be in relatively good health. :HRI’s analysis reveals that the average age of the newly insured will be just 33. Thus, “providers are not likely to be immediately overburdened.”

What many forget is that, unless he is in pain, the average American under 65 is not terribly eager to see a doctor.  Going to the doctor typically means taking time off work, sitting in a waiting room for 30 or 45 minutes, disrobing, waiting for the doctor to note that you’ve gained 10 pounds, answering questions about how many beers you drink each week, and worst of all, there is the possibility that you will receive bad news – news that you really don’t want to hear.

State Elections, and Medicaid Expansion

With all eyes focused on the presidential election, healthcare writers tend to forget that state elections also are having an impact on reform.

Writing on AHL Alerts: American Health Line’s Blog, Michelle Stuckey takes a look at gubernatorial races  and  reveals one reason why so many governors have delayed stating their position on Medicaid expansion In 11 states, the governor’s mansion is up for grabs, and  “most incumbent governors up for re-election have been hesitant to state their position on the Medicaid mandate,” she expalins.

Stuckey  lists the 11 states hosting gubernatorial races and notes that in just three of them (Delaware, Vermont and Washington) gubernatorial candidates have come out in favor of the expansion.  But this doesn’t necessarily mean that the other eight are opposed to opening the door to Medicaid.

Most are playing their cared close to their vest,  she reports, quoting Kip Piper, of Sellers Dorsey, a Medicaid and health reform advisory firm: “There are strong strategic reasons for a gubernatorial candidate to not show their hand.”

Candidates and incumbent governors might be delaying a formal decision on expansion, he argues, because:

  • They are waiting to use expansion as a bargaining chip in negotiations for federal waivers, such as waivers for Medicaid reform or integrated Medicare-Medicaid plans for dual eligibles;
  • They want to avoid making new political enemies; or
  • CMS will issue new guidance to comply with the Supreme Court’s ruling.

My guess is that the second reason trumps the other two. Candidates don’t what to declare where they stand on Medicaid expansion because they know that, in many states, it’s a third-rail issue –and they want to avoid making new enemies.

Medicaid expansion is controversial: many voters fear that their states simply can’t afford it.  But in fact, the federal government will be paying 100% percent of the tab from 2014 through 2019– 90% thereafter.

No  Moreover, if Medicaid is expanded, states will save much of the money that they now spend helping public hospitals and clinics cover unpaid bills. With more poor people on Medicaid, those piles of unpaid bills will shrink.

As a result, while California is expected to shell out “about $195 million for expanding Medicaid when the federal government pays 90 percent in 2020” it is projected that it “it would save  more than $2 billion in uncompensated care. Similarly, Wyoming would save about $1 million, and Montana would save about $9 million.”

 Federal Medicaid dollars will help state economies by creating jobs for nurses, lab workers, and others. Meanwhile   both hospitals and insurance companies will lobby state legislatures and governors to accept expansion: they want more paying customers.

Politicians know this, and once the gubernatorial elections are over, my guess is that, in most states, the winners will agree (however reluctantly) to take Washington’s money.

“Death Panels”\

While the Affordable Care ACt was being drafted, Sarah Palin started a rumor that reformers planned to set up “death panels” of  cost-conscious bureaucrasts who would decide when it is time to pull the plug on elderly, dying patients.

Of course, there were no such panels in the reform legislation.

The rumor was based on a  provision in early drafts of the law that would have let Medicare cover the cost of “optional” end-of-life counseling: Medicare would reimburse doctors for taking the time to talk to older patients who wanted to talk about how they felt about “heroic measures” being taken to keep them alive during their final weeks or months of life. What if they stopped breathing? Would they want to be resuscitated?  Would they want to be put on a breathing marchine that would breathe for them.

 Ideally, these conversations would take place before patients  were sick– at a time when they  could ask questions and think clearly about their choices. 

But like many “Big Lies,” fear-mongering about “death panels” was effective, and the idea of letting Medicare pay for the counseling was dropped from the bill.

Since then, the myth has been thoroughly debunked, and these days, few worry about death panels –except Henry Stern.

On InsureBlog he recently wrote a post headlined “Liverpool Not Just for Beatles”  where he reports that  Britain’s National Health Service has a new ‘End of Life Care Registry’ which takes the “Liverpool Pathway program “to new heights (or depths).”

Stern explains that he has written about the Liverpool Pathway in the past, calling it a “Death March” used to cut costs “by allowing medical staff to withhold fluid and drugs in a patient’s final days.”

In fact, according to the Daily Mail, the program involves withdrawing treatment, sedating the patient, and removing tubes providing food and fluid” during the last 24 hours of his  life. “It was devised in the 1990s as a means of easing pain for the dying, and has been in widespread use in the NHS in recent years. However, critics claiim it is increasingly being applied to patients without their families’ knowledge and when they still have a chance of recovery.”

Not everyone agrees with the critics:   In the UK,  the Catholic Herald quotes Dr Peter Saunders, head of the Christian Medical Fellowship and a strong opponent of euthanasia, saying: “The overwhelming majority of people on the LCP (Liverpool Care Pathway) are experiencing much better care at the end of life than they would have had if it had not been chosen.” 

Still, it is hard to know who to believe–the families, or the doctors?

The crucial question, it seems to me, is whether the patient was given a chance to voice his preference as to how he would like to die. Neither doctors’ druthers nor his family’s wants and wishes should determine his fate.

This is why the original provision in the Affordable Care Act was such a good idea: it encouraged doctors to talk to patients about dying, giving them time to think about their options and express their wishes. If they were dying, doctors determined that there was no hope of recorvery, would they prefer to fight to the end? Would they want to continue receiving food and water,or would they want the feeding tubes removed?  (Palliative care specialists explain that patients can be kept quite comfortable even while food and water are withdrawn under controlled condtitions. This is not like starving to death, or dying of thirst in a desert. )

According to Stern, the UK has now gone a step further and is encouraging doctors to draw up lists of patients who they believe are close to death, “singling them out to be allowed to die in comfort rather than being given life-saving treatment in hospital.” He calls the lists “death registers,” and writes that “although more than 7,000 patients nationwide have already been put on the list, there appears to be no obligation for doctors to inform them.”

If true, this is, indeed, deeply troubling. But the word  ”appears” suggests uncertainty. 

This led me to Google “end-of-life registers” and ”UK.”  What  I found suggests that tpatients are, indeed, aware of being on the register.  According to the National Health Service: “The use of Advance Care Planning” in Somerset “also allows patient’s to document their preferred priorities for care and the End of Life Register will allow patients preferences and needs to be communicated among staff and organisations who are responsible for their care, either now, or in the future.” 

My Google search turned up many similar articles.

Finallly ,what does Stern’s post have to do with end-of-life care in the U.S.?

Nothing. No provision in the Affordable Care Act has ever encouraged doctors to do anything except follow a dying patients’  wishes. We do have “registries” such as Montana’s End-of-Life Registry but “it stores advance health care directives in a secure computer database and makes these documents available to health care providers.

“Moreover, “Advance directives are not used as long as an individual is able to express his or her own decisions on whether to accept or refuse medical treatment. They are used only when an attending health care provider determines that someone is in a terminal condition and is no longer able to participate in making decisions regarding medical treatment.” In other words, you can change your mind.

If Romney Wins, Will Health Care Reform Continue On the Ground?

Yes, because, as a result of the national  conversation surrounding reform, more and more Americans understand that our health care system is broken.A great many patients and  doctors now realize that something must change. 

At the same time, dialogue about reform has begun to discover solutions: teamwork; “lean” (less wasteful) medicine; fewer unncessary tests and treatments;  greater transparency regarding prices, and, finally, safer care. Far too many patients are actually harmed by medical care.

Reform will roll forward, without or without full support from Washington, thanks to people like Brown University’s  brave and knowledgable Dr. Roy Poses, who has  made many aware of the corruption in our profit-driven health care system.  The problem is not just that U.S. health care is too expensive.  It is dangerous.

In a recent blog on Healthcare Renewal, Poses published a post headlined: ”When Clinical Trials are Meant for Marketing, not Science.”   In that piece he reports that recent litigation reveals that Parke-Davis/ Pfizer marketers pursued a publications strategy to encourage use of Neurontin off-label.  In other words, the marketers systematically commissioned and controlled the design, implementation, analysis and dissemination of multiple clinical trials to try to persuade physicians to use the drug for indications not approved by the FDA.”  

On Meaningful HIT News, Neil Versel joins Poses in explaining to his readers that “we do not have the best healthcare in the world.”  Not long ago, Versel directed readers to ” a recent commentary in the WSJ about how the broken culture of medicine is harming people, include an eye-opening infographic from the movie ‘Escape Fire’ which reveals that medical errors’ are now ‘the third-leading killer in the U.S”  right behind ‘cancer’ and ‘heart disease.’”

On the  Health Business Blog, a post by David E, Williams titled “New England Compounding Center: the Avastin/Lucentis connection“  raises a nother red flag, calling for a more pro-active FDA, arguing that the Agency should  be called upon to police so-called “compounding pharmacies” that in reality act as drug manufacturers.

Weary of the Incessant Focus on the U.S. and our  Election?

Finally, for those interested in taking a break from obsessing over what is going on in  Washington, Julie Ferguson, the guiding spirit behind Health Wonk Review, offers a post written by Jon Coppelman of Workers’ Comp Insider,

He  looks at the high rates of chronic kidney disease (CKD) among  workers who grow and harvest sugar cane:

“A standard day for an El Salvadorian sugar worker lasts between four and five hours, with double shifts during the summer planting season, when temperatures top out at 104 degrees.

“Héctor García, a 33 year old with stage-two kidney failure says: ‘It’s very hot; we suffer. People sometimes collapse. More often they vomit, especially when the heat is worse. They do two shifts to earn more money.’ Another worker, 40 years old and close to death with stage five CKD, reported the same symptoms, compounded by the limited resources in his home: ‘When I come home, I feel surrendered. Sick. Headache. I can’t shower because the water [from the roof-mounted tank] is too hot.’”

 

 

10 thoughts on “The Pre-Election Edition of Health Wonk Review: Fact vs. Fiction

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