Sunday, December 26, 2010

Medicare end-of-life conversation regulation

The lead news item in today's edition of the New York Times is the Obama administration's decision to create a new Medicare regulation regarding paying physicians to discuss end-of-life issues with their patients.

Given the Administration's need to work with Republicans on a host of important issues I am sure that this decision is not a political strategy intended to enhance President Obama's prospects for reelection in 2012. It may actually have at effect, however. I think it increases the probability that Republican leaders will be unable to prevent Sarah Palin becoming the party's presidential nominee. In a race in which Palin is the Republican nominee for president, Obama is more likely to win.

We are certainly going to hear increasingly angry statements about "death squads" from the far right and characterizations of President Obama in the most negative ways, often couched in fundamentalist religious frames. For many, this is not about reason. For many, this is about government's intrusion on the sacred domain of the Almighty. Years ago, little could be done to prolong the lives of terminally ill people. Following death, doctors spoke the words, "we did all we could." And that was it. No one, and certainly not "bureaucrats" working for the national government were held responsible for "killing Grandma." Now that the burden of financing medical care falls increasingly on government, government itself is a risk of being blamed for the intensely personal consequences of the necessary rationing of medical care.

I have at least three concerns. One, I am concerned for our nation. It is not written in stone somewhere that the United States will always continue to exist in its present configuration. Issues that deeply divide the nation which some citizens see as nonnegotiable are a threat to the fabric of our nation. Two, creating policies/regulations regarding what conversations are reimbursed and what conversations between physician and patient are not reimbursed seems to me to be a bit troubling. I mean, do we really want to create a situation in which primary care physicians may say to a patient, "I am sorry but we have only fifteen minutes and I would prefer to talk with you about some topic for which my group practice will get reimbursed." Third, creating a system by which physicians are paid to talk to patients about end of life issues is one step away from specifying by regulation what the patient can (and cannot) be told by his or her physician.

The reality is that a large percentage of what is spent for medical care in the United States is spent to lengthen the lives of people who are near death in any case. This is a difficult call because in many situations the nearness of death is uncertain. It is likely that new technologies will increase the percentage of near-death spending in coming years. The potential need for medical care is almost infinite. Resources are finite. Rationing by some means is necessary. People do not want to make hard choices. We want it all. In the name of social equity, we want it all for everyone. It is "easy" for me to write this now working from what I perceive to be a rational perspective. It is more difficult to face these things in situations in which rationality may not be the primary criteria for decision.

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