More Healthcare Reform Stuff I Haven’t Talked About

While I’m on the subject of topics in the discussion of healthcare reform on which I haven’t commented, I haven’t commented on the end-of-life counseling provisions in some of the measures before Congress, either. Do I find it more troubling that physicians aren’t compensated for the time they spend discussing difficult subjects with their patients or that they should be incentivized to initiate discussions of entering hospices with their patients?

I suppose I could take the position that professionals have responsibilities to those they serve and, if they need to have a billing code for everything they do, they might consider another way of earning a living. Too idealistic, I guess.

There are other things in the provisions that I think should concern us, too. Should physicians be required to cover specific topics in these counseling sessions? They are, under the current bills. Should they required to report the results to federal authorities? They’re required to do that, too. There’s more to be concerned about than just the counseling provisions and I’m rather surprised that more physicians haven’t complained about them.

8 comments… add one
  • Arjun Link

    I don’t have an opinion about the provisions, but I really liked this posting. “I suppose I could take the position that professionals have responsibilities to those they serve”: Yes. A patient just got roomed so I will comment more later.

  • Arjun Link

    I thought Dr. Krauthammer’s column on the end-of-life-please provision in today’s Washington Post was great.

    I’ve been thinking about professional standards in medicine recently, because their alleged erosion has been in the news: there was a famous article by Dr. Gawande in the New Yorker about Medicare costs in McAllen, Texas, and there was an interview of Kenneth Arrow by Conor Clarke in the Atlantic. Another patient just got roomed.

  • The other day, I received an interesting and very instructive e-mail from my brother Jeff who lives in France. He asked me to share it with the readers of my blog. I think I will share it with you also.

    “HELLO, AMERICA!

    “As an American who has been living in Europe for most of the last 20 years, one who has visited doctors numerous times in four different countries, whose two children were brought into this world in European hospitals (France and England), who has himself spent a week in a public British hospital, and who underwent an operation in a private British clinic, I think I can say a thing or two about health care in Europe.

    “Our out of pocket expenses for the births? Zero, even though in France my wife spent 5 days in the hospital after the birth, which is standard, by the way.

    “During the three years we lived in England, we never once paid for medicine for our children. Children get drugs for free in the UK. Visits to the GP are free for everybody.

    “My expenses for the week in the NHS hospital? Zero.

    “The cost of the operation in the private clinic? Zero, it was covered by my work insurance, as was the post-op physical therapy I needed.

    “In Western Europe you would never be forced to sell your home in order to pay for your medical bills, as happens all too often in America when catastrophic illness strikes and the insurance company decides that your condition was ‘pre-existing’.

    “The quality of the care? Mostly good. French hospitals are excellent, even the food is decent. The food at the NHS hospital was beyond awful, but then again most English food is pretty bad (though they do have great Indian food). At night, they were understaffed, but I am guessing that, apart from that place where Dr. House works, most American hospitals are understaffed at night, too.

    “In short, in the US, you pay more, get less, and die younger than we do in Europe. What part of that don’t you understand?

    “My fellow Americans, you have nothing to fear except those who would use fear to keep you enslaved to the myth of the might of the American health care system.”

    Jeff Degan

    What can I tell you? The guy is a Communist. Not only does he live in France, he actually likes it there. An eternal shame to our family’s good name. Let us boil down his seven paragraphs to their juicy essentials, shall we?

    HEALTH CARE IN THIS COUNTRY SUCKS.

    Here is (Excuse me, I meant to say, “Here was“) a golden opportunity for real reform and the idiotic Americans are screaming about socialism. Is it any wonder that we have become the laughingstock of the Western world?

    http://www.tomdegan.blogspot.com

    Tom Degan
    Goshen, NY

    PS – I love English food!

  • Arjun Link

    According to Mr. Degan, Americans are “idiots” and America is “the laughingstock of the Western world”.

    Like Mr. Schuler said: The Lost Art of Persuasion.

  • steve Link

    From my POV this end of life provision was a true positive in the bill. First, it is mandatory and is only every 5 years. No one is making a lot of money off of this. Next, this is a conversation that will occur between a patient and their primary care doc. Primary care guys have little fiduciary interest either way in the big ticket items that run up costs at the end of life. We specialists do, but we are not likely to be doing these consults. Next, the primary care doc is the one who will best know the patient. The doc can explain the technical aspects of end of life care and help guide the patient to a decision that is consistent with their wishes and beliefs. For example, if the patient is a devout Catholic, the primary care guy can make it clear to the patient that they may want to specifically put in clauses in their living will that will not conflict with Church doctrine. Otherwise, they risk having a distant relative who does not know them making the decisions.

    Almost every night I am on call, and often during the day, I am faced with patients who have never talked over these end of life decisions. If they have a spouse still alive that sometimes helps, but I frequently end up on the phone with a son, daughter, cousin who tells me they have no idea what Dad/Mom would have wanted. So, we do everything. That is at variance with my experience of discussing these issues with most people who tell me that they do not want care if there is no hope that it will help. Many tell me that they would like to die at home or without tubes everywhere. What we are doing now is not working in getting people to address these issues. If paying for a consult once every 5 years will nudge people in that direction, it will be a boon for those of us dealing with these issues.

    Steve

  • To be honest, Steve, the part that bothered me more was what I saw as the violation of privilege rather than the incentivizing of the discussion.

    I also think that these discussions should begin in primary school rather than when one is seriously ill, possibly in a final decline, but that’s another subject.

  • Drew Link

    Steve –

    I think the primary objection is that in a government funded setting the discussion is not a pure doctor-patient discussion (which I think most people agree is a neglected subject) but would would be corrupted by financing considerations.

    I think the concerns are valid.

  • steve Link

    Drew-Then the same would hold true in any Dr./patient conversation about any other aspect of health care. A heart surgeon recommends a CABG is because of financial considerations. A Cardiologist recommends stents due to financial considerations. If this were really the case all of the time, then our outcomes should be worse than in socialized countries where the docs are on salaries. Instead, we see that our outcomes are pretty much the same as in other first world countries. (Though to be fair, there is data that shows that in areas with higher than average utilization of medical services, outcomes are worse.)

    I am thinking that if this is once every 5 years it is small potatoes for the physician. I am also thinking that if consumers are smart enough to make good choices about their health care purchasing, as advocated by free market advocates, they should surely be smart enough to figure out if a doc is steering them towards a path intended to help the government’s pocketbook. Of course if the government is has this kind of power over physician decision making, why not just have us not offer the expensive stuff to begin with? Given that Medicare does little to directly interfere with physician spending now, it would take a major change from the current situation.

    Steve

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