Death Panel Myth Debunked - Prioritizing Patient Education

American healthcare’s mostly fee-for-service reimbursement model encourages doctors to order tests and procedures so as to make a reasonable living from practicing medicine. There is no incentive to have conversations with patients. Unfortunately, when their patients have to face decisions about what they want to happen (or not happen) as they near death, they need to talk over their options-- not receive a final MRI. When Obamacare was in its formative stage, a provision was introduced that would have required Medicare to pay for a voluntary discussion about advance directives and end-of-life treatment preferences. Geriatricians, palliative care doctors and hospice staffers welcomed this potential statutory provision, but the political opposition for whom the entire Affordable Care Act was anathema went ballistic. They made accusations that this was the precursor to government-sponsored euthanasia, or as Sarah Palin infamously put it, “death panels”.

 

Seven years of increasing public recognition that end-of-life issues were humane and necessary has recently borne fruit. Now healthcare professionals can punch in a code to bill Medicare for such discussions and receive $80-$85 for a 30-minute “consult” and $75 more for an additional half-hour interchange. Moreover, if the conversation needs to be reopened at a later date, Medicare will again provide compensation. Will this change in Medicare reimbursement solve the problem that only a third or less of patients over 75 and those with debilitating, chronic diseases presently have such interactions?

 

Certainly, there is little financial incentive, as this level of hourly reimbursement is not going to significantly impact physician income. Moreover, private insurers have not yet followed Medicare’s lead. Most importantly, the significant impediments to success are patient and physician awareness and education. Patients must be informed that these services exist and are available and that they are not tantamount to signing a consent form to withhold all further medical treatment. The documents generated and options chosen must be known to families and available at points of service, not left in drawers and safes. Appointed healthcare proxies must know they have been selected to fulfill their role. On the other side of the conversation, the medical community has not suddenly been endowed with the ability to respectfully broach and explore these very sensitive subjects. These kinds of communications require training and perhaps certification of aptitude.

 

So will there be a sudden surge in end-of-life discussions? Probably not, but the Federal Government is the elephant in the room and has taken the first step and sent a powerful message about the value of these conversations. Even a journey of a thousand miles requires an initial step.

 

By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton

 

Why Would a Doctor Abandon a Steady Paycheck to Become an Entrepreneur?

As physicians, we are expected to be compliant with rules, restrictions, and regulations. We are expected to be risk averse. We are expected to be “providers,” but not necessarily innovators or leaders. As the healthcare system becomes increasingly consolidated into large overcrowded clinics, we are required to perform to the standards set by bureaucrats and clinic managers. These rules are often at odds with the best interests of patients and with our sanity.

The Alienation Of America’s Best Doctors

The best and the brightest simply don’t want to become doctors anymore. Physicians are burning out. They are leaving the profession. They are going bankrupt. They are selling their private practices to big hospitals. They are retiring early. We are facing a growing doctor shortage.

Better to Live and Die in the U.S.A.

The United States healthcare system is often berated for how it treats patients near the end of life. They are purportedly attached to tubes and machines and subjected to unnecessary invasive procedures that cause inordinate pain with no potential benefit, there is underutilization of more compassionate hospice services. This “travesty” is expensive, as the care of dying seniors consumes over 25% of Medicare expenditures. We hear this story so often; it is almost taken as gospel-- but is it actually true? Is it more expensive and invasive to die in America than in other developed countries?

Gun Ownership and Doctors?

According to the Pew Research Center, there are approximately 32,000 gun-related deaths annually in the United States; 19,000 are suicide, 11,000 are homicide, and the rest are accidents, police shootings or of unknown causation. Moreover, there are more than 78,000 nonfatal gun wounds each year. Given the disproportionate number of victims that are less than 40 years of age, the morbidity and mortality of gun violence is significant. Physicians are involved with many types of public health issues, but few are as controversial or divisive as gun safety. Is it really an issue that falls within the medical domain?

O Tempora, O Mores: Affordable Care Act - Big Dream or Big Let Down?

I confess I was a strong proponent of the Affordable Care Act. My reasoning was subtler than the hallowed pantheons of its staunch supporters and the apocalyptic predictions of its detractors. Forty years after graduating medical school I concluded, after many stutter steps, the American healthcare delivery system was economically unsustainable and the citizenry was neither living longer, nor better, despite medical expenditures that dwarf any other developed nation. My career also allowed me to personally interact with cardiac surgeons from all continents and see that their clinical results and research efforts were laudatory by any standards.

High Depression Rates in Resident Physicians — Fact or Fiction?

The December 8, 2015 issue of JAMA had a startling key clinical point; the prevalence of depression or depressive symptoms among resident physicians in training was 28.8%. The data was generated by meta-analysis of 31 cross-sectional and 23 longitudinal studies published in peer-reviewed journals involving 17,560 trainees. Two-thirds of the trainees were in North America, but the others were from Asia, Europe, South America, and one from Africa. Sensitivity-analysis confirmed that no individual study affected overall prevalence by more than 1% and that the incidence of depression was not influenced by study design, continent of origin, surgical vs nonsurgical program nor level of residency year.

Can a Robot Outperform Your Surgeon?

In the current competitive environment, healthcare providers often attempt to separate themselves from their competition by marketing themselves as using the newest technologies for their procedures. This is an age defined by finding the next best thing and the American public responds to this strategy. My personal experience has been in cardiac surgery, but the principles are equally applicable to other specialties, particularly tertiary referral practices.

Hospital Administration Attempts to Cut Costs and Increase Quality at Expense of Physicians

A nonprofit hospital care system in Oregon with 450 beds has been in an acrimonious negotiation with its staff hospitalists for the past 2 years. The mounting economic pressures on this small, community oriented institution have had the expected consequences of hiring new administrators to implement the latest trends to rein in the budget and effect efficiencies of healthcare delivery-- as if that has been so successful in the rest of the country. The battle has really centered over the physicians losing control of their work time allocation, individual decision-making for diagnostic and treatment plans, as well as bristling at bonuses based on the administration’s definition of quality.

Michigan Physicians Society Supports Inner-City Education

Yesterday afternoon I had the privilege of helping to honor the graduating class of 2016 at Experiencia Preparatory Academy. They have 3 graduates this year that have overcome a special set of challenges, including moving from Mexico to the United States and having English as a second language.

Affordable Care Act: Affordable for whom?

Entering its third annual open enrollment period, Obamacare is the subject of cacophonous political acrimony, again, championed by its supporters and vilified by its opponents. Each side presents its own “metrics” of success or failure

Big Pharma Using Mail-Order Pharmacies to Maintain High Prices

The United States has the dubious honor of paying the highest prescription drug costs in the world. Many healthcare economists attribute this to relatively lax cost regulation compared to other wealthy countries; however, a decade of insurers paying only for generic drugs when available and limiting drug choice in specific formularies has had little modulating effect.
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