being honest about health care reform

Charles Krauthammer is concerned about the language in the health care reform bill HR 3200, and makes his concerns known in an essay titled Let’s Be Honest about Death Counseling.

Noting that the bill contains a provision in section 1233 for a Medicare-paid advance care planning consutation between the patient and the doctor, Krauthammer opines:

What do you think such a chat would be like? Do you think the doctor will go on and on about the fantastic new million-dollar high-tech gizmo that can prolong the patient’s otherwise hopeless condition for another six months? Or do you think he’s going to talk about — as the bill specifically spells out — hospice care and palliative care and other ways of letting go of life?

Yes, the bill says that the doctor must mention palliative care and hospice options. Specifically, the consultation must include, among other things:

(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

The sentence containing the words "palliative care and hospice" clearly puts them in the context of "the continuum of end-of-life services and supports". As I read it, there's nothing in the bill to prevent the physician from getting paid if he or she advocates heroic life-sustaining treatment even in the most hopeless cases, as long as the range of options is discussed in the consutation.

Now it may be the case that Krauthammer does not read it the same way, and it may be the case that he would like to see the other side of the continuum spelled out in more detail. That's a valid concern; perhaps the language is not clear enough, and this section of the bill should be modified. That's a reasonable criticism.

After a brief digression into why he thinks living wills are worthless and irrelevant, Krauthammer returns to the reform bill, concluding:

So why get Medicare to pay the doctor to do the counseling? Because we know that if this white-coated authority whose chosen vocation is curing and healing is the one opening your mind to hospice and palliative care, we’ve nudged you ever so slightly toward letting go.

It’s not an outrage. It’s surely not a death panel. But it is subtle pressure applied by society through your doctor. And when you include it in a health-care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it’s intended to gently point you in a certain direction, toward the corner of the sick room where stands a ghostly figure, scythe in hand, offering release.

Were it not for this conclusion, I'd believe Krauthammer was voicing an honest concern about the bill. But his final two paragraphs make no sense whatsoever, unless we make one huge assumption: That physicians can't think for themselves; that they are incapable of doing anything unless Medicare orders it.

I worked for a medical billing agency for ten years. I can't imagine a competent physician would ever say, "Since Medicare is paying for this consultation, I should probably advise my patient to choose death." The reaction will probably be more along the lines of, "Medicare isn't paying any more than that?" Because that's the general reaction to anything Medicare pays for.

Medicare, in my experience, is actually less bureaucratic than most private insurances, but it requires physicians to take deep, deep discounts. And since Medicare patients usually need more care than patients with private insurance, doctors must take these discounts on a high percentage of their services.

As I stated above, I don't see anything in the bill requiring physicians to push their patients toward palliative care for chronic illnesses. I can't imagine any physician would read the bill that way either. I certainly can't imagine a physician would advise patients to opt out of any care that might cure their condition.

Only someone filled with disdain for the medical community would suggest otherwise.