Come, eavesdrop on a Death Panel discussion . . .

Today's Wall Street Journal lead editorial confirmed what I wrote in my last column: that the new provision in CMS regulations paying for end-of-life discussions between Medicare beneficiaries and their physicians is actually a good thing. You might have a hard time coming to that conclusion, because the WSJ's approval was buried in a series of tirades against the President and the CMS bureaucracy, as well as a glowing endorsement of Sarah Palin's prescient understanding of the dangers of socialized medicine.
Sidebar: it's becoming increasingly clear that NewsCorp owns the WSJ, as the editorials get snarkier. At least Mr. Murdoch hasn't ruined the reporting. Yet.
I can't vouch for what President Obama would say to a senior, nor what a Council of Liberal Democratic Senators might impose upon that poor Medicare beneficiary, but I can tell you what I talk about when I have these end-of-life discussions with patients.
Here's the first thing you should know: in my experience, physicians only mention "hospice" and "palliative care" in passing, and then someone else - someone who's paid a lesser salary - actually shares the details with the patient. That someone might be a social worker, or a nurse, or somebody like me.
Maybe because I'm not on the government payroll, I don't know any better, but rather than imposing a guilt trip on Granddad ("don't you know that by clinging to life, you're depriving your grandchildren of a decent standard of living??"), I start by listening. I ask a series of questions, to find out what this person believes about life, about quality of life, about family and relationships, about what's most important. And then I listen.
We talk about mortality. The WSJ said it today: no matter how much we improve medical care, we still haven't found a cure for death. Mortality is still 100%. So what we really think about is life-sustaining or death-delaying, and, to put it simply, at what point is death a better option than life.
The reason that so many political pundits on both sides of the aisle are having trouble with the whole "death panel" issue is not their political persuasion. It's something much, much deeper. It's because they haven't dealt with their own mortality. They're scared to death of dying. When I speak with elderly patients about life and death, they are usually at peace with the idea. It's their grown kids (usually the same age as Sarah Palin, or thereabouts) who can't deal with it. This same latent fear is what causes people to say irrational things and make irrational decisions in the political sphere.
We talk about prognosis. That's a fancy word for what we expect the outcome to be. Specifically, what will the outcome be if we do everything, and if we do nothing (or something in-between). On my ball field (oncology), physicians and patients often have conversations about what treatments are available, but sometimes - maybe often - they don't really talk seriously about whether any of those interventions will make a real difference in survival or quality of life. Thus I have seen patients die in the ICU after spending two months on a ventilator, and I wonder, would they have chosen this death?
We talk about how long is long enough. An 89 year old with metastatic lung cancer may decide she's lived a good life and doesn't want to go through the treatment gauntlet for another four months. A 38 year old mother of three with advanced breast cancer, on the other hand, may value as precious beyond price the opportunity to spend the extra two months with her kids (the median improvement in progression free survival from Avastin) that treatment might buy her.
We talk about Quality of Life . . . the elusive, enigmatic quality of life. The problem with quality of life is how to define it. Unfortunately, medical professionals often, arrogantly, assume to define quality of life for their patients. We even try to calculate treatment effectiveness in terms of "quality-adjusted life years." The problem is that nobody can define quality of life for a patient except the patient himself. So what I have to do is ask the patient, "what does 'quality of life' mean for you?" For some it's freedom from pain, or anxiety. For others, it's preservation of autonomy. For some people, quality of life means being allowed to fight for survival to the last breath. For others it means spending their life savings on a trip to Italy, rather than three weeks in the ICU.
After I've listened to the patient talk about what's important to him, we can move to the part of the interview where I talk and the patient listens. I'll tell you about that in the next installment of "Miranda Writes."

Death Panels return! (Not).

It was reported Sun., Dec. 26, in the New York Times, that the Centers for Medicare and Medicaid (CMS) released new rules that allow physicians to counsel Medicare beneficiaries about end-of-life issues. That's not a very accurate description of what happened.
What actually happened was that CMS, as required by the Patient Protection and Affordable Care Act (hereafter referred to as PPACA), instituted coverage for annual wellness visits for Medicare beneficiaries, covered at 100%. Furthermore, part of that annual wellness visit may include a discussion between the patient and the physician about the patient's desires regarding end-of-life care.
Now this is important, so read carefully and slowly: PPACA only annualizes the "Welcome to Medicare" wellness visit instituted by CMS under George W. Bush. Permission to discuss end-of-life care (and be paid for it) was instituted under the Bush presidency. All PPACA did was to provide that opportunity annually, rather than just once, when the beneficiary first becomes entitled to Medicare.
Unlike the ill-fated "death panel" provision of the health reform bill, which was edited out in the final version of PPACA, these new CMS regs do not prescribe the content of the conversation between the physician and patient. And, to quell the fears of Libertarians everywhere, if you knew what Medicare pays a doctor to do an annual physical, you wouldn't waste the first bead of sweat worrying about wholesale efforts by physicians to lead seniors to slaughter. It's just not worth the doctor's time to hold extended discussions about living wills and withdrawal of care.
What I can tell you, from my personal experience, is that, contrary to the ravings of Betsy McCaughey, Rush Limbaugh and Sarah Palin, neither physicians nor the government are interested in pressuring seniors to die quickly to save Medicare's money. In fact, most physicians don't seem to want to have the end-of-life conversation at all.
Think about it. How comfortable would you be discussing death and dying with all of your clients or customers? Our reticence to have these discussions probably do cost the taxpayer money that could have been saved if better decisions were made. But much more importantly, our unwillingness to have those discussions results in untold pain and suffering that could have been avoided otherwise.
Here is what I've seen with my own eyes, in my job, at my hospital:

• patients spending the last three weeks (or three months) of their lives on a respirator, sedated to dull the pain and paralyzed with drugs to overcome the instinctual struggle to yank foreign objects out of their throats.
• patients sweating from fever, yellow from jaundice, swollen like footballs, with every pore of their skin weeping lymphatic fluid, their skin tearing in places and bruising in others, their fingers and toes becoming gangrenous.
• patients with their ribs broken and their lungs punctured from multiple attempts to revive them with CPR, only to last a couple more weeks virtually brain dead before their organs finally shut down.
• families torn apart - sometimes not speaking with each other for years - because of conflict about decisions made at the bedside in the absence of the patient's clearly expressed wishes.
• husbands and wives feeling guilty - feeling like they killed their loved one - because they were asked to make to decide to "pull the plug," without knowing the patient's wishes.

Situations like these can be avoided if only a physician and a patient can sit down, as signs start to point toward impending mortality, and have an open, frank, supportive discussion about the patient's beliefs and wishes before there is a crisis.
In my next article, I'll tell you what we talk about when we have these "death panel" discussions with patients.

The End of The World As We Know It

I looked to the North. Nothing. I looked to the East. Again, nothing. I looked to the South. Empty. I looked to the West. No sign of 'em.

I've been looking every day since then, but no sign of the Four Horsemen of the Apocalypse. Not even a Don Quixote tilting at windmills. But House Minority Leader John Boehner prophesied that it would be Armageddon if the health care reform bill passed. My cellar is packed with canned goods and gallon jugs of water, duct tape and extra loaded clips for my Glock. But nothing. Only the whistling wind and the occasional tumbleweed rolling by.

Did the Republicans overreact? I mean, if we really were on the eve of Armageddon, the death threats leveled against pro-health-reform Democrats were almost justified. Sarah Palin's PAC facebook page would be responding appropriately by marking the US map with gun sights on the states where she is targeting Democrats for defeat in the upcoming elections.

If it is the end times for anyone, it's so for the Republicans. The Republicans rolled snake eyes. They gambled big, choosing to put their trust in political, Machiavellian maneuverings rather than making a good-faith attempt to influence the final version of the reform bill. They may win the upcoming battles of 2010, unseating a handful of Democrats in weakly-held positions. But they lost the war - the war of ideals, the war of standards, the war of accountability to their constituents.

You can tell by reading past blogs that I have, for the most part, supported health care reform, though with many caveats about the bill that passed. But my philosophy is that it's better to pass a flawed bill - which is, in its worst case scenario, an improvement over the status quo - and then set forth improving the bill piece by piece. The Republicans, had they been true to their calling as statesmen, would have fought like hell to remove provisions they sincerely could not support, and fought even harder to add provisions they believed strongly in that were absent.

Instead, the Republicans chose to stand as one against any meaningful reform, because they were more concerned with breaking Obama's back and chipping away at the Democratic majority in a selfish consolidation of power than they were with providing access to affordable health care without breaking the Treasury. Because of their damn-the-poor, take-care-of-our-own-kind mentality, the Republicans succeeded in allowing the liberal fringe to overload the bill with expensive and ultimately unaffordable provisions.

Will the world end? No. It didn't end when FDR pushed Social Security through Congress, nor did it end when LBJ strong-armed Medicare into being. Heck, the world didn't even end when LBJ shepherded the Civil Rights Act through Congress in 1965, in spite of dire predictions from most of the racist white parents of my friends growing up in Alabama. And it's not going to end today, in spite of Boehner, and Glenn Beck, and Rush Limbaugh (who still hasn't moved to Costa Rica, as he promised).

What I fervently pray is that the world - as they know it - comes to an end for the Republican leadership, who showed their true, elitist, narcissistic stripes in the health care reform battle. Because they only pretend to look out for their constituency (well . . . they actually do take care of their core constituency: the super rich).

If I may dare to be inflammatory, I think the real issue is the the current leadership of the Right (not just the GOP, but the Tea Party and other loosely assembled groups) is motivated by their racism more than they are by any beliefs about health care, or immigration, or jobs. The sad fact that you can turn on Talk Radio at any given time of the day and hear aspersions cast on our President because of his name (Obama) his ethnicity (AFRICAN American) slanderous claims to his Muslim (read RADICAL) beliefs and questions as to his American birthright. People don't deliver death threats over taxation and health policy. People burn crosses, and flags, because of much deeper-seated, much more dangerous, unexamined prejudices.

Leadership that genuinely believes these lies deserves to be unseated. Leadership that cynically plays to these fears is even more deserving of ostracism.

Ten GOP health ideas for Obama revisited

Newt Gingrich and John Goodman published an op-ed in today's Wall Street Journal purporting to answer President Obama's challenge to the Republican party to come to the table with their ideas for health care reform. This dynamic duo presented some good ideas - some of them even fabulous - but, the devil being in the details, Newt (who seems to be on a first-name basis with Mephistopheles) fails to provide them (the details, that is).
Let's look at these ten ideas presented by Gingrich and Goodman (hereafter referred to G&G, to save my typing fingers) and evaluate if (1) they are good ideas; (2) they are practical ideas, reasonably implemented; and (3) if they achieve the two goals of reducing cost and enhancing quality.

• "Make insurance affordable." Turn these stones to bread. G&G purport to pass this idea off as a new one: provide tax credits to individuals who buy insurance up to a limit, which would exclude "Cadillac" health plans from a generous tax benefit. Wait a minute! Didn't I already read that somewhere . . . oh, yes! The Senate health care reform bill! G&G, dressing up an old idea in new semantics doesn't make it a new idea. But it is, after all, a good idea. Here's a better one - and let's see how conservative you really are - let's do away with tax credits and deductions altogether for health insurance. That'll put everyone on a level playing field. The more insurance you buy (or get from your employer), the more tax you pay on the veiled income that employer-provided health insurance actually is. Boy, wouldn't this put price pressure on the health insurance industry when consumers actually have to bear the whole cost of their insurance coverage. Score: Good idea? Yes. Easily implemented? No. Reduces cost? Yes. Improves quality? probably not.
  

• "Make health insurance portable." Yes, this is a good idea, too. Too bad the Republicans didn't think of it. It's been around for a while, in particular, touted by health care economists. Change federal law so that individuals can buy insurance plans offered to large pools, much like we buy auto insurance. Cut the employer out of the deal altogether. Let the employer increase wages in lieu of purchasing insurance. Or let the employer pocket the difference as a windfall, and then watch their best employees defect to their competition. This will still require regulation of the insurance industry, especially if group insurance goes away and everyone buys his or her own plan. For instance, exemptions or price increases for pre-existing conditions will have to be outlawed. Score: Good idea. Not easily implemented. Reduces cost (possibly). Improves quality: not.

• "Meet the needs of the chronically ill." Newt wants to give the chronically ill their own Health Savings Accounts and put them in charge of their own medical decisions. Newt, we're not in Kansas anymore. HSAs are great for people who are healthy. They don't work for people with ongoing, major medical expenses. You simply can't keep the money in the bank. And lumping the chronically ill in a special-needs plan may (or may not) improve their health status, but it certainly won't save money. It's a bee-line to insolvency. Furthermore, the health needs of the chronically ill are typically very complex and difficult to manage. To expect the patient to expertly manage those decisons (and the money to pay for them) is not only naive, but grossly unfair to the patient. Concentrating on the needs of the chronically ill might be a good idea, but it is NOT health care reform that reduces costs and improves quality. Consolation: it would be relatively easy to implement, by building on the experience of current Medicare Advantage Special Needs plans. Score: 1 for 4.

• "Allow doctors and patients to control costs." G&G use a deceptive tactic here: call a duck an alligator. What they suggest in this paragraph is not cost control by doctors and patients, but changing the reimbursement system so that physicians are paid for good outcomes, not for the number of relative value units (medical jargon for widgets) they produce. Again, G&G, not only has this idea already been suggested - way before either House or Senate bill - but this idea is actually incorporated in both bills. And this is probably the best idea so far. It can be implemented, with some hardship. Already there are demonstration projects in action that reimburse providers based on quality patient outcomes: medical homes, accountable care organizations, etc. This idea will actually reduce costs and improve quality! To bad Newt can't take credit for it. Score: 4 for 4.

• "Don't cut Medicare." Are you kidding?! What's the alternative, Newt? You didn't offer one. How do you plan to avert the program's insolvency if we continue on its current path? Every right-minded economist agrees that to save Medicare we're going to have to cut benefits, increase taxes, or increase age of entitlement (and probably a mixture of all three). The only possible alternative, and it won't solve the problem alone, is to change the way Medicare pays providers (see the paragraph immediately above). Score: F-. The perfect politician's answer: tell people what they want to hear even if it's pure insanity.

• "Protect early retirees." G&G write that "more than 80 percent of the 78 million baby boomers will likely retire before they become eligible for Medicare." Not of those 78 million baby boomers bought into the same mutual funds that I did. It's tough to be a millionaire, Newt! It's just so darned hard to keep touch with reality! But let's entertain Newt's delirium for a moment. Say a sizable number of baby boomers do retire before 65. If we reform our health care financing system to provide portable, affordable, individual insurance options, coupled with HSAs, then these baby boomers will be able to continue their insurance coverage until Medicare kicks in. And they'll probably have to continue that coverage afterward to make up for what Medicare will no longer be able to cover. Score: OK idea. Somewhat reasonable to implement. May or may not save money. Has no effect on quality.

• "Inform consumers." Patients need "clear, reliable data about cost and quality," write G&G, before they can make decisions about their care. How true. In fact, Medicare is already publishing data (www.hhs.medicare.gov) comparing hospitals and nursing homes. Eventually, this type of information will be available for all providers. True, it's not there yet. However, even with reliable data on quality and cost, patients are still woefully unprepared to make decisions about appropriate therapies. They will still need expert advice from their physicians. Score: well, Newt didn't think of this one either, and this idea is already in the Democrats' current plans.

• "Eliminate junk lawsuits." I agree. Score: 4 for 4. And damn those Democrats for being in the breast pocket of the trial lawyers' lobby.

• "Stop health-care fraud!" Thanks, Newt! I'm glad you thought of that. What's wrong with those crazy liberals? Why didn't they think of it? We can all go home now. Here's one: End the war. Or, here's another one: End World Hunger! No, wait: even better: End Global Warming! Peace in our time! There's no place like home! Seriously, even if the figure G&G throw on the page - $120 billion annually lost to fraud - it's a drop in the bucket compared to what we need to do to reduce costs. News flash, Newt: there are a couple of guys running around trying to stop health care fraud. They work for the OIG. And yes, G&G, you're right in implying that massive adoption of electronic medical records and transactions will help to reduce fraud. Wait a minute . . . didn't somebody already talk about electronic records? No, it wasn't ... omigod, yes, Ted Kennedy, demigod poster child of socialized medicine. Wasn't that the whole point of the Kennedy-Kassenbaum act? Newt! What a strange bedfellow for you!

• "Make medical breakthroughs accessible to patients." Good idea: maybe. Every time the FDA does speed up the process, the other half of America becomes hysterical about the FDA being in bed with the drug industry, foisting expensive and dangerous treatments on us without carefully vetting them. Cutting FDA red tape - will that reduce costs? Most assuredly. Will it increase quality? Probably quite the opposite. Making medical advances rapidly available . . . wanna see health care costs eat 40% of GDP? This is a good start. We have to find a way to balance medical technology enhancements with affordability and safety. Another good idea on paper. Not practical. Certainly not cost-effective. Probably not quality enhancing.

Newt and John, when all is said and done, you guys did ok. Not great, but ok. Original? Hardly. Republican? Only if Nancy Pelosi has changed parties. Do we need to start from scratch? Hardly. There are many good ideas already in the legislation. There are a heck of a lot of ideas that need to be purged, as well. So Newt, Nancy, et al: quit playing politics and wasting our time. Get to work!

Can't We All Just Get Along?

Thank you, Rodney King.

The election of Mass. Sen.-elect Scott Brown (Republican for the People) is a good thing. Without a supermajority, the Democrats can't push through their agenda with impunity. Heck, they couldn't push it through WITH a supermajority! Conversely, the Republicans can't play the role of helpless victims, because they now hold the power to - if nothing else - filibuster.
So now is the time to re-approach health care reform. Not that it will happen. That would require Democrats to grow backbones, and we all know that evolution doesn't happen that fast. The President was right to chide his colleagues and tell them not to head for the hills. If you didn't know better, you'd think the Republicans had taken back the House and Senate. They got one little ol' senate seat, for God's sake. The Democrats still hold 57 seats. They remind me of the French, ready to surrender at the drop of a hat.

As I said, NOW is the time to tackle health care reform again. Why? Because now the Republicans have to actually respond. Either they have to collaborate with the Democrats, or they have to put up roadblocks. And now that they'll need Republican support to pass a reform bill, the Democrats will have to play nice in the sandbox and be willing to compromise on some of their issues.

For the Republicans' part, they will have to either cooperate or obfuscate. Which means, ultimately, if the Democrats can push a more conciliatory bill through, the Republicans will be forced to filibuster. And if that bill is more palatable to the American people (as it'll have to be even to get on the floor again), the Republicans will be perceived as anti- working class American, and anti-small business, if they prevent a bill from passing.

The question is whether President Obama has the wherewithal to persuade his party to get back on the horse. If he can do that, he is the consummate politician of our age.

Massachusetts sees RED

Looks like the Republican candidate to fill the late Sen. Edward Kennedy's seat will beat his Democratic opponent, the attorney general of Massachusetts . With 23% of precincts reporting (as of this writing), Republican Scott Brown was leading Democrat Martha Coakley by 53% to 46%. Brown ran on an anti-health care reform bill platform. He plans to be the 41st Nay vote, which will probably kill the bill that eventually comes out of conference committee, because the Democrats won't be able to end a Republican filibuster.

How ironic that the death of Ted Kennedy, the foremost crusader for universal health care, triggered the turn of events that will probably kill any chance of health care reform in this Congress.

The Democratic leadership must now decide if they are willing to moderate their plan enough to make it palatable to more moderate Republicans in the event a compromise can be reached. Word from Nancy Pelosi's office is that the House Democratic leadership is not willing to compromise that much. So my prediction is that health care reform will be ambushed from both sides (liberal Democrats and Republicans) and will fail to pass in this session of Congress.

That's too bad, because even the worst possible iteration of the proposed reform plan was better than the status quo. And if Congress fails to pass legislation, there will be no real incentive within industry to generate these reforms on their own. At least, not quickly enough to save the broken health care system.

Here are some of the things I would like to see in the final compromise bill, if it had a snowball's chance of passing:

• the Public Option. I know this is one of the most unpopular elements; however, a public plan managed by the Office of Personnel Management (the OPM, which manages the federal government's "Cadillac" health plan), with prices negotiated with providers, rather than set by legislative fiat, although more expensive in the short run than expanding Medicare and Medicaid, would be sustainable in the long run. Expanding the current government programs will just increase the burden on providers to care for even more patients at a net financial loss, which will drive providers out of the CMS programs in droves.
• a 15% tax on Cadillac health plans - including collective-bargained union plans (why should unions be exempt?). A 40% tax is repressive and counterproductive. A lower tax would generate revenue without driving generous health care plans to extinction.
• increase the Medicare tax cap on individuals earning more than $500,000 a year, or couples earning more than $1 million a year.
• Increase Medicaid coverage to persons earning at or below 133% of Federal Poverty Level (150% is unsustainably high).
• Allow health insurance companies to offer plans across state lines (this will allow them to increase their risk pools and consequently hold down prices).
• Regulate individual plans to require a minimum level of value (i.e., out of pocket caps; more generous coverage limits; limited gaps in coverage).
• Disallow exclusions and premium increases for pre-existing conditions.
• Put much more emphasis on reform of health care delivery, as opposed to just health care financing. For instance, expand the demonstration projects on accountable care organizations, medical homes, regional health information repositories - programs that will reduce waste and duplication, reward providers for quality and wellness/prevention gains, and penalize them for overutilization and sub-standard practices.
• Finally, we waste more money in the billing/collection/denial/appeal game. It is estimated that about 24 cents of every health care dollar is spent on back-end paper-shuffling. So standardize electronic data interchange and claims payments. Make hospital set real prices, as opposed to wildly inflated "monopoly money" pricing. Make payers, in turn, cover a larger percentage of charges and limit their loopholes for withholding or denying payment.

The success of the health care reform movement is in grave jeopardy. If it fails, it will be up to us in the industry to make incremental gains in quality and cost-effectiveness. We've already proven incapable or unwilling. God help you if Congress fails.

Pooch is still a virgin: Senate passes HCR bill

OK. I was wrong. I predicted in this space that the Senate would fail to pass a meaningful health care reform bill. But in fact Harry Reid (with the President's help) was able to cobble together a supermajority and pass a health care reform bill. It was not without compromise, and a lot of political hay was made about the bacon that got fried to get the bill passed.
Nebraska won't have to pay for any of the cost of expanding Medicaid coverage in that state. One New England medical school hospital will get an extra $100 million. And a handful of other bribes. The Republicans are disingenuous to point the finger at the deal-making, since this is the way Congress has operated from its inception (remember the reason we have two houses of Congress was to get the small states to vote for the Constitution in the first place).
Conservative wingers and liberal wingers ("fringe" is a more appropriate term) would have been happier - or would have felt morally superior - if they had been able to defeat this bill: the left because it was too watered-down - a sell-out - and the right because it portended the inexorable march of socialism across our land. Thankfully, both fringes were unsucccessful.
Not that the Senate bill is the panacea. It is riddled with flaws and weaknesses. But it's a far sight better than the status quo, as is the House bill, as well. We simply could not continue on the road we were on. The truth is that, whatever compromise we end up with passing both houses will reduce the rate of spending growth and will eventually reduce the deficit, as well.
The right thing to do for the American people is to hammer out a bill in conference committee that can pass into law. It won't be perfect. Far from it. But, as I said above, it'll be better than where we would have ended up without a bill. Once the bill becomes law, Congress can begin the work of hammering out the dents and improving the law brick by brick.