Sunday, August 9, 2009

Tonsillectomies, Part Two

On July 22, President Obama talked about health care and said:

Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. So if they're looking and you come in and you've got a bad sore throat or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, "You know what? I make a lot more money if I take this kid's tonsils out."

Now, that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies. Maybe they have something else that would make a difference.

This statement was greeted with derision on the Right, as it should have been. It portrayed doctors as greedy opportunists who cared nothing for their patients’ well-being and made treatment decisions based solely on how much money they could squeeze out of the system. Jim Geraghty at the Campaign Spot wrote a July 23 post called “Is the Most Justifiable Criticism of Obama That He ‘Still Seems Too Good to Be True’?” in which he expressed incredulity at a sycophantic reviewer of Obama’s performance by asking:

He saw the claim of America's doctors engaging in tonsil profiteering, right?

Now Geraghty has up a post recommending an article by Charles Lane at the Washington Post. Lane has written about the House’s overreach in their health care bill (HR3200), specifically (you guessed it) Section 1233 under which Medicare will now pay for an end of life counseling session. I’ve already explained (here, here, and here) why I don’t share Lane’s concerns and I’m not going to get into that again.

I was, however, struck by something in the paragraphs Geraghty quoted from Lane’s article (emphasis mine):

Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren't quite "purely voluntary," as Rep. Sander M. Levin (D-Mich.) asserts. To me, "purely voluntary" means "not unless the patient requests one." Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that's an incentive to insist.

Patients may refuse without penalty, but many will bow to white-coated authority. Once they're in the meeting, the bill does permit "formulation" of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would "place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign," I don't think he's being realistic.

. . Ideally, the delicate decisions about how to manage life's end would be made in a setting that is neutral in both appearance and fact. Yes, it's good to have a doctor's perspective. But Section 1233 goes beyond facilitating doctor input to preferring it. Indeed, the measure would have an interested party — the government — recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations. You don't have to be a right-wing wacko to question that approach.

So physicians who would never participate in “tonsil profiteering” will be more than willing to “insist” their elderly patients undergo end of life counseling where the doctors will “sell” the patients on living wills and hospices and “pressure” them to sign on the dotted line - all for a little extra money (which, incidentally, the doctor gets whether the patient signs something or not). What shall we call this? “Death profiteering” seems awfully harsh and “euthanasia profiteering” is almost worse. “End of life profiteering” is a mouthful and “1233 profiteering” is a little obscure.

I know. How about “granny profiteering”? I think it has a nice ring to it.


Anonymous said...

I want to know who the political genius was who decided that a bill meant to address the federal deficit by reducing the nation's health costs should include provisions for using tax funds to pay doctors to counsel elderly patients about terminating costly treatment. Not to mention the Death Panel. There's a crowd-pleaser for you.

They start hanging ornaments on these Christmas trees to buy votes, and they don't look at the overall effect.

-- Texan99

Elise said...

They start hanging ornaments on these Christmas trees to buy votes, and they don't look at the overall effect.

Yup. I just put up a post about the Democrats shooting themselves in the foot with the optics of the thing - never mind the substance.

So what is this "Death Panel"? I know Sarah Palin referred to it but I haven't tracked down where the reference came from.

Anonymous said...

Section 1233 has this language: (b) Expansion of Physician Quality Reporting Initiative for End of Life Care-
. . .
‘(A) IN GENERAL- For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.
‘(B) PROPOSED SET OF MEASURES- The Secretary shall publish in the Federal Register proposed quality measures on end of life care and advanced care planning that the Secretary determines are described in subparagraph (A) and would be appropriate for eligible professionals to use to submit data to the Secretary. The Secretary shall provide for a period of public comment on such set of measures before finalizing such proposed measures.’.

I'm not sure if this is it, or all of it. I'll come back and look some more later.

-- Texan99

Elise said...

Oh, okay. I talked about that in one of my posts. I truly don't think it's a big deal and suspect there is some government regulation somewhere that requires effectiveness measures be attached to all legislation. The idea is that if the government is going to spend money on something - paying for end of life counseling - they have to come up with some metrics to show whether the something is being used (are people using the counseling) and how well it works.

This last is tricky. There's not going to be any way to measure how many counseling sessions result in a living will or OLST* so what the language seems to want the Secretary to do is figure out if end of life wishes are being respected. It would be nice if someone could do that (she says, thinking once again of her aunt) but I don't see how you can.


* Actually this I might be persuaded to worry about. It's possible the government will decide to require physicians to indicate the outcome of the counseling session in order to get paid. You know, a checkbox thing:

This session resulted in (check all that apply):

living will
advance care directive
none of the above

It's possible (I consider it highly unlikely) the government will consider in the future only paying for counseling sessions that produce a document. Of more concern to me is that this would be a violation of patient privilege. Just as the doctor shouldn't be allowed to tell the Feds what my liver function test showed he also shouldn't be allowed to tell the Feds whether I signed a living will.

More generally it's totally bizarre to me that those who oppose HR3200 and the other similar health care bills aren't pushing back more on the privacy angle. Surely that would be an area where conservatives, libertarians, and liberals could make common cause.