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Friday, October 9, 2009

Do the Math: What Happens when Bureaucrats Counsel Patients?

The Church Report, published my Op-Ed today on healthcare, bureaucrats and end-of-life "counseling":

When 53-year-old Randy Stroup of Dexter, Ore., applied to Oregon's state-run health plan for help with his chemotherapy, bureaucrats sent him back a letter. The letter stated that the state would not cover his chemotherapy but would pay for the cost of an assisted suicide.

The incident revealed an important truth about government health bureaucrats: they are not always compassionate, but they are good at math.

The latest U.S. Senate healthcare reform proposal, by Montana Democrat Sen. Max Baucus, recently raised a ruckus by calling for reducing Medicare payments "by five percent if an aggregation of the physician's resource use is at or above the 90th percentile of national utilization."

Grading on such a curve, physicians who provide the least care win. When the government calls the shots in medicine, cost can replace care as the measure of effectiveness.

That’s why some U.S. legislators have triggered protests by proposing to have government bureaucrats virtually barge into the physician’s exam room by funding the counseling of patients about end-of-life considerations. Concerns grew even more when the assisted suicide group Compassion & Choices bragged of helping to shape the counseling clause.

“America's Affordable Health Choices Act” (HR 3200) in Section 1233 directs government funds to pay healthcare professionals to give patients “an explanation of orders regarding life sustaining treatment or similar orders, which shall include--the reasons why the development of such an order is beneficial to the individual and the individual's family…”

Note that the one-sided “counseling” includes no information about why such an order might not be beneficial to the individual.

Of course, counseling by impartial experts and determining written guidelines for end-of-life decisions can be helpful, especially when the patient also secures a personal proxy whose devotion to her welfare is unquestioned. Yet while advance directives may be used to specify the continuance of or quality of care, in actual practice they tend to emphasize limitations on care. Advance directives also offer no guarantee that a healthcare institution will actually follow the patient’s wishes in a healthcare crisis.

A study published in the New England Journal of Medicine put it bluntly: “The effectiveness of written advance directives is limited by inattention to them.”

In a paper aptly titled, “The Limited Wisdom of Advance Directives,” the President’s Council on Bioethics noted, “Advance directives cannot be understood in the abstract, separate from the specific context in which they emerged or the legal and public policy environment in which they now operate.”

The context of the end-of-life “counseling” program of HR 3200 is the bill’s explicitly stated purpose--to “reduce the growth in health care spending.” As health bureaucrats in assisted suicide states like Oregon and Washington have quickly discovered, premature deaths are cheaper than care.

Even absent legal assisted suicide, government bureaucrats can save money simply by convincing patients to accept a denial of care, and to put it in writing through an advance directive.

The context of state-sponsored chats with patients about their expensive end-of-life care also includes President Obama’s revealing call for “a very difficult democratic conversation” about “those toward the end of their lives [who] are accounting for potentially 80 percent of the total health care bill out here.” Actually, a study of Medicare dollars spent during the last year of life, published some time ago in the New England Journal of Medicine put the figure at 30 percent. But the President’s statement revealed a utilitarian focus on saving money by cutting care toward the end of life.

The counseling context is also found in the writing of Dr. Ezekiel Emanuel, a health policy advisor to President Obama and brother of the President’s chief of staff. Dr. Emanuel has written that some medical services should not be guaranteed to those “who are irreversibly prevented from being or becoming participating citizens....An obvious example is not guaranteeing health services to patients with dementia.”

With just 41 percent of Americans supporting President Obama’s healthcare reform plan, the President and his Congressional allies would like us all to forget such revealing statements and simply heed their reassuring sales pitch.

The vast majority of American patients who want to keep the government out of their private conversations with their physicians simply aren’t buying it.
  • P.S. If you're not buying it, either, you can do something about it. Contact your legislators and tell them to keep the government out of end-of-life counseling.

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