August 30, 2014

NYT: Here Come Those Government-Reimbursed ‘End-of-Life Talks’

In a Saturday evening story to appear on Page A1 in its Sunday print edition, Pam Belluck at the New York Times tells readers that “paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.” This apparently blessed development is occurring “After Sarah Palin’s ‘death panel’ label killed efforts to include it in the Affordable Care Act in 2009.”

Belluck seems fairly pleased that “Bypassing the political process, private insurers have begun reimbursing doctors for these ‘advance care planning’ conversations as interest in them rises along with the number of aging Americans.” (But of course, “private insurers” have really become inside cronies in “the political process” since Obamacare’s passage; so their involvement may really prove that behind-the-scenes government pressure to reimburse those “services” is working.)


The crucial question in all of this, which Belluck did not directly address, is whether these discussions are at the patients’ request or are initiated by the doctor. The answer appears to be far more of the latter, based on her description of how doctors currently handle them — “some doctors conduct such conversations for free or shoehorn them into other medical visits.” Why is that a problem? That follows the jump.

Jennifer Popik, a medical ethics attorney with National Right to Life, explained why at National Right to Life News in mid-July (HT Life News).

Early in her essay, Popik noted, as has been the case in so many areas during this administration, its implementation is being proposed, and if put into effect will be imposed, by going around Congress:

They may not be Death Panels, but they are Death Advocates, and they are back

In the time since the “advance care planning” provisions were struck from the Obama Health Care law, there have been several attempts to resurrect the concept through various stand-alone bills in the House and Senate. Now, according to media reports, the American Medical Association (AMA) is working directly with the Obama Administration to implement reimbursement by administrative action, bypassing Congress.

It is telling that the AMA is pushing this idea, because it’s an instant profit center in an era of tight-fisted govrenment reimbursements, with constant threats of further cutbacks. All that’s required to make more money is the creation and utilization of new medical codes.

Here’s why a regime of involuntary end-of-life discussions are overwhelmingly likely to cause far more life-ending results:

Such federally funded “advance care planning” conversations pose a very real danger, because they are likely to be used to nudge people to reject life-saving medical treatment they might otherwise want.

Advocates of using tax dollars to pay for “advance care planning” claim it is intended to promote neutral, fully informed planning by which patients can be assisted to implement their own values through legally valid advance directives. Unfortunately, however, there is abundant evidence that a combination of cost pressures and the ideological commitment of a significant number of health care providers to limitation of life-saving treatment for those deemed to have a “poor quality of life” would in practice lead to many federally funded advance care planning sessions being used to exercise subtle – or not-so-subtle – pressure to agree to reject life-preserving treatment.

… It has become widespread to now talk about treatment as being costly and burdensome, depending on one’s ‘quality of life.”

… In a taxpayer-funded advance care planning session, a patient with cancer might well be told chemotherapy provides little benefit because it will leave him or her with a disability and only “prolong life,” without a cure. The extra period of life might be exactly what a person would want, but because the treatment was presented in such a negative way the patient might well be lead to agree to reject treatment.

A major campaign (the subject of a forthcoming NRL News Today article) is now being waged to show videos to patients that are clearly weighted to persuade them to forego cardio-pulmonary resuscitation, and its proponents do not hesitate to cite the financial savings associated with the increased number of viewers (as opposed to patients not subjected to the videos) who agree to DNRs. Importantly, there is no apparent realistic way to adequately monitor the interactions in such tax-funded sessions to ensure that the presentation of options is done in a neutral way, rather than one biased toward rejection of treatment.

A precedent on the federal level is a Veterans Affairs patient decision-making aid that was the subject of considerable discussion during the debate over the Patient Protection and Affordable Care Act, a 53-page production entitled “Your Life, Your Choices.” The booklet had worksheets to fill out for “Current Health,” “Permanent Coma,” “Severe Dementia,” “Severe Stroke” and “A future situation of concern when I might not be able to express my wishes.”

For each of these there was a section on “quality of life.” Only for current health was there a choice to affirm that life is worth living without reservation.

Anyone who doesn’t believe that what was seen in the VA won’t occur on a national scale if involuntary end-of-life discussions become virtually automatically reimbursable services is kidding themselves.

Pam Belluck at the Times should have made clear that end-of-life counseling (mislabeled as “care”) is inevitably going to be about “nudging” unless there is a universal and enforceable requirement that patients must be the ones who initiate the discussions.

Cross-posted at


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