August 17th, 2009 by DrRob in Better Health Network, Health Policy, Opinion
2 Comments »
Death panels. They are all the trend these days.
I went to Home Depot to look for some, but couldn’t find any. There was some drywall of doom, tiles of the abyss, and sheet rock of destruction, but no panels. I guess the Obama administration has bought them all.
Honestly, I am not sure what the “death panel” fuss is about. Everyone dies. There are times it is a surprise, but many times it is expected. When it is expected, shouldn’t people plan for it? Shouldn’t we encourage people to plan for it?
The focus of a physician is twofold: to prolong life and to minimize suffering. We practice preventive medicine to keep the person from avoidable pain and/or death. The younger the patient is, the more we call their death things like tragic, pointless, and distressing. We go to great lengths to save the life of someone who has many potential years ahead.
But there is a point when things change. There is a point when the focus shifts from quantity of life to quality of life. There is a time after which a death is no longer tragic, but instead the end of a story. My focus as a physician shifts from trying to find and prevent disease, to maximizing function and minimizing pain. When does this happen? It depends on the health of the patient. But eventually, ignoring one’s inevitable end becomes more tragic than the end itself.
I had a man in my practice who had advanced Alzheimer’s disease. I cared for him before he started his decline, and so had a good chance to know both him and his family. They were people of strong faith, accepting the hard things in life as being from the hand of God. The children took their father’s condition not as a horrible burden, but an opportunity to pay back the man who had given them so much. There was no fear of illness or death.
His wife died fairly soon after I started caring for them. He grieved greatly when she died, but was so surrounded with the love of their children that his grief was short. He spoke often of her in subsequent visits, talking about her as if she was not far away.
As he became increasingly short in his memory, my relationship with their children grew. You can tell a lot about people from their children, and these children were a dazzling crown of honor to these two lovely people.They always came asking good questions, patiently dealing with their father’s confusion, anxiety, and occasional outbursts. Together we worked to maximize his quality of life. When I suggested we stop cholesterol medication and cancer screening tests, they understood. Our focus would not be on the length of life, but the quality of time they could spend with their father.
I was shocked, therefore, when the report of his admission to the hospital came across my desktop. He had chest pains and some difficulty breathing. In the emergency room, a plethora of lab tests, x-rays, and other studies were done. The hospitalist physician on call felt there was a good possibility of heart attack or pulmonary embolism (blood clot to the lung). My patient was sent to the ICU, where he underwent CT angiography, serial lab tests, and even a stress test to rule out heart problems.
I was mystified as I read these reports; the family clearly understood that prolonging his life wasn’t the goal. The patient was ready to die and join his wife, and the children were very comfortable talking about his eventual death. These reports made absolutely no sense with what I knew of this man and his family.
He looked his normal self when he came in to my office for a hospital follow-up. I questioned the daughter about the details of the admission, which she recounted carefully. Then I paused and asked her, “Can I ask you one more thing?”
She smiled at me, “Of course, Dr. Rob” she said gently.
“I was honestly a little surprised when I read about your father’s admission to the hospital. It seems like they pulled out all the stops, even putting him in the ICU. Did they ask you if this is what you wanted? I thought that you wouldn’t want to be that aggressive.”
She thought about what I said and a puzzled expression slowly appeared on her face.
“Did you ask to have everything done, or did you just follow what the doctors at the hospital told you?” I asked.
“They didn’t ask us. We just did what they told us we needed to do.” she said, now scowling slightly.
I explained to her that they need to make their wishes known in advance. If they don’t say anything, the doctors will assume that you agree with what they are doing. As I told her this, she nodded and looked down sadly.
“It’s OK what you did” I reassured her. I patted her father on the shoulder and added, “he looks great now. I am glad I get to see him again. I just want you to know what to do if it happens in the future. You never know what will happen, and I’d hate for him to suffer needlessly.”
This one short hospital stay undoubtedly amassed a bill many times that of all my bills over the 12 years I saw him in my office. My years of care, long conversations, and real personal connection built with this man and his family are worth only a fraction of a few days of unnecessary care. This care was not demanded by the family. It was not done because of denial or ignorance; it was because the family wasn’t prepared for the mechanics of the hospital stay. I never had that conversation with the family until after this event.
Politicians have labeled this merciful conversation as an act of rationing. That is not only ignorant, it is shameful. Talking to people about end-of-life issues will certainly save money. But it’s a contemptible step to imply that this money is saved by killing the elderly. It’s more wrong to make money off of keeping them alive unnecessarily than it is to save money by letting them die when they choose.
This is politics at its ugliest – taking a provision that will reduce suffering and help people and pervert it to be used as a tool to scare the people it will help. The discussion about healthcare has been subverted by those who want poll numbers.
Shame on you.
*This blog post was originally published at Musings of a Distractible Mind*
August 17th, 2009 by GruntDoc in Better Health Network, Health Policy, Opinion
No Comments »
John Mackey is the CEO of Whole Foods.
John Mackey: The Whole Foods Alternative to ObamaCare – WSJ.com
While we clearly need health-care reform, the last thing our country needs is a massive new health-care entitlement that will create hundreds of billions of dollars of new unfunded deficits and move us much closer to a government takeover of our health-care system. Instead, we should be trying to achieve reforms by moving in the opposite direction—toward less government control and more individual empowerment. Here are eight reforms that would greatly lower the cost of health care for everyone:
Make sure you read toward the end to see what the Whole Foods Canada employees ask for…
Update: the reality based community took this very well…
*This blog post was originally published at GruntDoc*
August 17th, 2009 by admin in Better Health Network, Health Policy, Opinion
No Comments »
By George Lundberg, MD
Just as “all politics is local”, so is all medical care personal. One patient; one physician; one moment; one decision. And in this era of balanced physician and patient autonomy, that decision often is an informed joint decision. Many patients now make serious efforts to learn about their conditions both before and after visits to their physicians. Many physicians welcome such informed patients and willingly discuss comparative effectiveness of the available diagnostic and therapeutic options. However, a frank discussion about the comparative costs and charges for the options, whether they be to the insurance company, Medicare, Medicaid or out-of-pocket for the patient, is usually missing.
Many health economists insist that the medical marketplace does not behave like other markets and believe it is fruitless to expect market principles to usefully inform the medical arena. That bias is true in emergencies,
operating rooms or intensive care units, and with patients who are mentally disabled.
Such behavior does not have to persist in an outpatient setting. In my book Severed Trust: Why American Medicine Hasn’t Been Fixed (Basic Books, 2000, paperback 2002), I presented the concept of “the economic informed consent.”
I believe that every patient who is mentally competent and in a non-emergency situation should be informed of the cost of a proposed diagnostic or therapeutic procedure or product, before it is “ordered.” This includes referral to another (often more specialized and costly) physician, no matter who pays the bill. The costs should all be discussed IN ADVANCE decision. This discussion should include whether it is worth it and
whether there a less expensive good alternative.
A recent NPR/KFF/HSPH survey reported that 55% of Americans believe that their insurance company should have to pay for an expensive treatment, even if has not been proven to be more effective than a less expensive
treatment. This attitude underlies the ruling convention, “if insurance will cover it, do it,” that lies at the root of our problem of health care cost inflation. No one is held accountable.
If we as a country could widely apply the “economic informed consent,” physicians and patients would become educated together. They could both become wiser shoppers for the most cost-effective diagnostic tests,
prescribed drugs, and specialists.
With an “economic informed consent,” physicians and patients can reset attitudes toward a healthy concern for the total costs or charges, stifling the usual knee-jerk response, “if the insurance covers it, do it.” No one
knows whether this approach, diligently applied, would actually cut down on wasteful spending, such as choices that drive huge geographic variations, but we do know that pricing an automobile, an airplane ticket, a dinner or a bottle of wine does affect consumer decisions. Why not try it for medical charges as well? Current sweeping proposals for health system reform all state that there must be “cost control” but offer little likelihood of delivering real cost savings.
Now is the time for the US Health Information Technology Initiative to create inter-operative systems that would provide the data to support widespread use of the “economic informed consent” in a timely fashion and
let the medical marketplace speak. Knowing the cost of a medical decision in advance should become a part of a new “Patient’s Bill of Rights”. In a medical care decision, it is the right of a patient to know “who pays whom
how much for what.” All of us in health care laud “transparency”–let that include economic transparency.
George D. Lundberg MD
President and Board Chair, www.lundberginstitute.org
August 16th, 2009 by Happy Hospitalist in Better Health Network, Humor
No Comments »
A humorous slam at private insurance companies. I read the whole article and wonder how much better life would be, not only for doctors but for patients as well if their third party paid a reasonable bundled fee, with profit potential, and let the patients and the doctors and the hospitals figure out how to divvy up the money. This humor is a take on private insurance companies, but it might as well be the government behind the Medicare National Bank. Neither has been able to control the cost of delivering health care to the masses. The only way to do that is to stop paying for it.
So, Mr. President, I write to you with this demand: we are not a socialist country, one which believes the health of its citizens should come without the proper profit-loss determinations. I believe that my healthcare decisions should be between me, my insurance company plan, my insurance company’s list of approved doctors I am allowed to see and treatments I am allowed to get, my insurance company’s claims department, the insurance company doctors who have never met me, spoken to me or even personally looked at my files, my own preexisting conditions, my insurance company’s crack cost-review and retroactive cancellation and denial squads, my insurance company’s executives and board of directors, my insurance company’s profit requirements, the shareholders, my employer, and my doctor.
via Surgeonsblog
*This blog post was originally published at A Happy Hospitalist*
August 14th, 2009 by Shadowfax in Better Health Network, Opinion
No Comments »
Congress is going into recess without completing its work on health insurance reform, and the advocacy groups are eager to use this time to whip up voter sentiment for or against reform. Unfortunately, the anti-reform pundits are all-too-ready to dip right back into the 1993 playbook that gave us Harry & Louise, playing on the fears of consumers with distortions and outright lies.
Ramona alerted me to one such piece published in the CNN/Money-Fortune segment, a “Special Report,” scarily titled:
Nice lede, eh? Can you guess without reading the article where this author is coming from?
The subsequent bits range from “accurate-but-deliberately distorted” to “complete BS that I made up but is really scary.”
Let’s start with the latter, as it’s more fun:
5. Freedom to choose your doctors
The Senate bill requires that Americans buying through the exchanges […] must get their care through something called “medical home.” Medical home is similar to an HMO. You’re assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.
Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. […]
The bills do not specifically rule out fee-for-service plans as options to be offered through the exchanges.
So, just to recap: You won’t be able to choose your doctors because your primary care doctor (that you chose) might, under certain reimbursement schemes that aren’t actually mandated in the bill, have a hypothetical incentive to limit access to specialists.
Um, what?
Never mind the fact that TODAY, right now, your access to a specialist is limited by some drone at your insurance company who doesn’t have a medical degree and does have a very powerful direct financial incentive to deny authorization for referrals. Never mind the fact that there is nothing in the bill which states you will be “assigned” to a primary care doctor. Never mind that fact that the “Medical Home” is not in any way related to an HMO, conceptually or practically. This “gatekeeper” function isn’t in the bill at all! The medical home concept is designed not to ration care (which is the unspoken subtext of the above passage) but to coordinate and improve the quality of care. Never mind that, if a referral is granted by the wicked & parsimonious gatekeeper, your choice of a doctor is still not restricted under the bill.
Never mind all those inconvenient little facts that each individually or all together totally invalidate the thrust of the author’s argument. The problem for the whole concept is that there will be many plans offered for purchase on the exchange. If you don’t like the one you picked because it is too restrictive, you can switch to another plan! If WellPoint requires too much hassle to get to see a specialist, then you can dump them and pick Cigna! Granted, the ones which are more restrictive are also probably going to be cheaper, but that’s for the consumer to choose!
And yes, before you bother to say it, yes, this might result in adverse selection of sicker patients into the more lenient plans, but they will be risk-adjusted to correct for imbalances in their patient populations.
So that’s the easy point to debunk, and I would think that finishing up with the BIG LIE like that, there would be little need to review the rest of the hit-piece, but I’ll make the effort, my love of truth and good policy being as strong as it is. Other “freedoms” you would lose, according to the esteemed and honorable author:
1. Freedom to choose what’s in your plan
3. Freedom to choose high-deductible coverage
I put these together, because it’s a bit of a cheat on the author’s part to list them separately. I mean, it’s the same thing, innit? This is basically an assault on the concept of the mandate that all Americans be insured: you can’t just buy crappy insurance that doesn’t really cover anything meaningful and say that you’re covered. I respect those libertarians I have clashed with when they say that they should be free to “go naked” if they so choose, and have no or minimal insurance if that is their choice. I disagree, but I respect their honesty. This piece is a little less direct, but it’s basically the same thing — defending the right of people to choose crappy insurance that wouldn’t actually cover their health care needs should they fall ill.
There are two problems with that sort of policy approach. First, a fig leaf just ain’t clothing. You can glue one on and walk around town without getting arrested, but everybody who sees you knows you’re naked. Insurance that has the “We never pay” clause just isn’t actually insurance. It doesn’t accomplish the actual goal of getting every American access to quality health care.
The other problem, a bit more subtle, is that letting people opt out of health insurance, either explicitly or de facto by buying cheap fig-leaf insurance, defeats the purpose of the individual mandate: risk pooling. It’s a certainty that some of us are going to get sick. It’s also certain that those of us who do become sick will not be able to pay our individual costs, as health care is now so expensive that no individual can hope to pay their actual bills. By requiring all of us to have insurance, you create a situation where those huge costs are spread out among the largest possible number of people. Allowing opt-outs ensures that everybody who can, will, and these will be the healthier people who don’t see a need for insurance, at least not today. The result is a concentration of costs among the sick people who generate the most costs, which, as noted, exceed the ability of these individuals to pay. Of course, as people who were healthy become ill, according to nature’s inexorable dictates, they will transition from the low-cost insurance products they previously favored to the ruinously expensive plans that actually cover for people who are sick. And the system literally falls apart. No funding exists for the sick to pay for their (hugely expensive) health care, and the healthy contribute little (until they become sick).
2. Freedom to be rewarded for healthy living, or pay your real costs
This is pretty tightly related to the above point, with a slight distinction. Again, as pointed out, nobody who is sick can pay their real costs. So again, there’s the risk-pooling issue. But there’s another, more pernicious assumption here: that health is a controllable feature of lifestyle.
Bullshit. I’m healthy, and I like to assume that’s because I’m virtuous and athletic and take care of myself. Right? Except that it’s strictly a matter of luck that it was not my kid that got sick and died of neuroblastoma. Or medulloblastoma. It was a matter of luck that my wife pointed out a funny-looking freckle that turned out to be a very thin melanoma (and lucky for her that she married someone who could tell the difference). Cancer is easy to cite, but the list goes on and on of health conditions that have nothing to do with lifestyle: crohn’s disease, MS, bipolar, Type 1 diabetes, glomerulosclerosis, etc, etc, etc. And none of us know in advance when our — or our family’s — number is up.
So we are all in this together. We all pay a premium: and bet or a hedge against illness. Those of us who win the genetic lottery and stay healthy lose the “bet” and wind up paying for a service we didn’t need. If you let some people hitch a free ride and pay a minimal premium, they are not paying their fair share to cover the cost of those who have already become ill. When President Obama talks about “Shared Responsibility,” this is what he means.
There’s a lot more chicanery in this article — I’ve neglected Point #4 entirely, as I covered that the other day. No plan will remain the same in perpetuity. I’ll stick to the main policy points and leave, for the moment, the sly little insinuations and falsehoods scattered throughout the article like so many candy sprinkles on an ice cream cone.
Strangely enough, I’ve finally found a point of serious, substantive agreement with (former) Alaska governor Palin. She and I are united in wishing that the gosh-darned liberal media would just stop making stuff up.
*This blog post was originally published at Movin' Meat*
