Tuesday, December 28, 2010

About Those Death Panels - More Overreach

The left is on the defensive over federal funding to incentive doctors to counsel patients to forgo aggressive end of life treatment, aka "death panels." I am not arguing that doctors shouldn't have a discussion about end of life treatment and patients make their wishes known ahead of time rather than in extremis. Good planning is good planning. But here is why I object to the regulations: (For a full explanation of the issues see the BWD article and read the comments.)
  • Under what sane system can the administration impose regulation explicitly rejected in the law by the Congress? (This is why this example gets the coveted dictatorial overreach moniker.)
  • The regulation provides for unlimited number of discussions, albeit only annually. At some point how does this differ from your doctor bullying you?
  • The left argues, as they always seem to when caught in some shenanigans, that this rule was first implemented under Bush. As if George Bush was suddenly elevated to paragon status by the left. I point out that under Bush doctors could only be reimbursed for this once.
  • Why did Democrat Earl Blumenauer tell supporters of the rule to keep it quiet?
  • Those supporting the regulation refuse to admit that the government has a financial interest in encouraging patients to forgo treatment. You can argue the merits of the regulation, but denying the government's financial interest is dishonest. And frankly, that's what gives average Americans the creeps. If the administration can incentivize the discussion, what's to stop them from incentivizing the outcome. What lack of awareness causes the left to be blind to this?

If you disagree, please comment.


  1. I wrote about this at the Daily Caller too and the fact that the left is so defensive about this tells me everything I need to know!


  2. LCR, thanks. Nice article. Keep up the nice work on the DC.

  3. Don't you think this death panel stuff is a bit overblown? There are death panels no matter what you do, it's just the composition of them that changes. It's the natural consequence of health care resources not being infinite.

  4. KT,
    True enough. This is why I want to get away from third party payer in health care. If people understood that the their life extending decisions impacted the inheritance they bequeathed their heirs, they might think differently about the situation. I am all for planning ahead for the inevitability of death. I am not in favor of the government influencing the discussion through incentives to doctors.

  5. Let us be consistent here. If Medicare has an interest in promoting death panels because they pay for care, by that same logic they have an interest in holding down payment now. The history of Medicare spending suggests otherwise.

    If you can take off your political goggles for a second, just imagine what I see nearly every week. A confused elderly patient shows up in the ER. They have some problem that might respond to surgery, but the chances are low. They have one or more co-existing diseases, often painful, that mean they are not going to live much longer even w/o this new problem.

    In this kind of situation, most people with end of life planning avoid heroic surgery. They opt for comfort measures. Family have time to come in and say goodbye before they die. W/o end of life planning, we go for the surgery. The patient often dies in the ICU on a vent. If they recover, they spend many of their last fews days in pain recovering from the surgery.

    In less dramatic scenarios, most people do not realize that hospice care is more than just letting people die. It is an active program to maximize functionality at the end of life. People, paradoxically, often live longer, have less pain and remain more functional for a longer period of time.

    End of life planning is the exception now. It should be the norm. Find me another way to do this, and we can drop the payment for end of life discussions.

    Also, on a personal note, I find it rather insulting that you think that docs would go ahead and tell people to just die so that we can make Medicare happy. Yes, there are sleazy docs, but not everyone is going to give up their practice standards.


  6. Steve,
    Thanks for commenting, you make some good points that I agree with. For instance, I don't think that doctor's are unethical. I just think that the system of third party payer inevitably leads to these kinds of distorted incentives. As I said in the post itself, good planning is worthwhile. Making a panicked decision when one's life is near its end makes no sense to me. I don't really mind a one time reimbursement for the doctor to have the discussion.
    But incentives work, even if slowly and over time. I want you to see that most people find it creepy that the institution that stands to gain financially is also encouraging people to die more quickly. It doesn't even matter that the discussion is worthwhile, it's still wrong for the government to encourage it, because we can't trust the motives of those pushing the discussion. It's really about the relationship or lack of thereof and the lack of trust in a faceless bureaucracy. My position is that this counseling is a good idea, but that government should not be in the business of providing incentives, because inevitably the government will pollute the dialog.

  7. B-Daddy- I can appreciate the general sentiment, but then you are left with the status quo. What alternative plan would get more people to engage in end of life planning? I also think that you need to remember that there are countervailing incentives. Medicare payments incent docs to do more already. But, here is the part most people miss. This discussion will take place between the patient and their primary care doc (PCP). That is not where the big dollars are being spent. The idea is to have the planning done before patients get to the specialists like me. That is where the big spending happens.

    For the PCPs, there will be little change in what they do regardless of what the patient decides. Inpatient care is now managed by hospitalists. With little direct financial interest, it should be a conversation aimed at best meeting a patient's needs. At any rate, thanks for listening.


  8. Bdaddy/ Steve,
    Thank you for such a sound discussion. I was moved by all of the comments.