Skip to main content

Death Panel Legacy

Yesterday, legislation that would have reimbursed physicians for advance care planning discussions was stripped from Medicare regulations related to the Affordable Care Act (Health Care Reform Bill).

This was the second time such language was removed.  The first time, of course, occurred during debate over the bill in congress.  Sarah Palin said she did not want Obama's "death panels" to decide who was worthy of care.  John Boehner (now house speaker) said the legislation was part of a slippery slope toward government sponsored euthanasia.  Not only was advance care planning legislation stripped from the bill, so were all measures related to palliative and end-of-life care.

What the administration couldn't get through congress it turned to regulation to accomplish.  On Christmas 2010, the New York Times broke the story that the Obama administration and Don Berwick, director of the Centers for Medicare and Medicaid, incorporated language into Medicare regulations related to the health care bill that would reimburse physicians for voluntary advance care planning discussions during the newly covered annual visit.  We didn't blog about this at GeriPal because representative Bleumenauer, author of the original legislation, cautioned against crowing about it, suggesting it should be a "quiet victory."

Now, preparing to defend the health care bill against a new republican majority in the house intent on repealing the Affordable Care Act, Obama has reversed course.  They claim the language was removed for procedural reasons, but anyone can read between the lines.

A few thoughts about this.

Physicians should be reimbursed for time spent conducting advance care planning discussions with patients.  This will incentivize high quality care.  Lack of reimbursement for these long discussions is a major barrier to outpatient doctors engaging patients in the advance care planning process.

On the other hand, if I were to chose palliative care priorities for the Obama administration to focus on, this would not be tops on my list.  Other issues I would rank higher (thanks to Diane Meier for many of these):

  • Funding for palliative care graduate medical education (fellowship spots)
  • Funding for palliative care research
  • Incorporating palliative care into Accountable Care Organizations
And if I had a choice between legislation/regulation that includes advance care planning, but was likely to get hammered in congressional debate and sink as a result, and legislation/regulation without the language but with all of the other good things the Affordable Care Act accomplishes...I'd take health care reform.

This issue is important.  It's just not worth the Obama administration falling on its sword.

by: Alex Smith


Dan Matlock said…
After the death panel stuff, I didn't even feel disappointed when I learned this AM that this was repealed. I just sort of smiled ot myslef. I guess I'm just numb. I agree 100% that there are bigger priorities and the last thing we want to do is lose the whole health reform.
I think this also shows the huge amount of education about Palliative Care that we still need.

I know very intelligent people that just don't understand what the AD discussion thing was about...add that to distrust of the government and it's a recipe for paranoia.

We need to keep trying to reach out to the public to help them understand advance care planning.
Helen Chen, MD said…
I can't say I'm surprised. What did surprise me was the tone of the comments related to the NYT story today. A lot of the writers felt that "doctors shouldn't get paid extra for something they should be doing anyway." Hmmmm.
In any case, our main focus now has to be on saving and advancing the aims of the Affordable Care Act. So many of the ACA's provisions benefit seniors--why aren't they up in arms about a potential repeal?
Eileen Kennedy said…
Ironically, the AD discussion will most likely save money in the long run because of the cost of end of life care. It seems so obvious, but there seems to be so much misunderstanding related to this topic. All of your comments as physicians are to be admired.
Stacy Fischer said…
I believe that the right wing news media's 'death panel blitz' has nothing to do with their misunderstanding or true fear of advance care planning. Those opposed to health care reform see a vulnerable issue to get the public sentiment whipped up. All that outcry was Fox news' and right wing talk shows' willful misrepresentation of the issue in order to accomplish their goal-to take down all of health care reform. If the right was truly fearful of rationing do you think we might hear the same outcry about Arizona's (R) Governor's decision to stop Medicaid funding for transplants? The withdrawl of the advance directive language will make no difference to the attempts to repeal health care reform. Advance care planning is simply collateral damage.
Mary Braun, MD said…
I think it would be fun to have a half day clinic where docs everywhere in the U.S. donated our time for the same four hours for the sole purpose of discussing advanced care planning with our patients. It would show legislators and the public how important we think advanced care planning is, how valuable our patients think it is and raise public awareness of what advanced care planning is and is not. On top of that, it would get a lot of patients thinking and planning with their doctors.

Popular posts from this blog

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Language Matters: Podcast with Brian Block and Anna DeForest

One of our first GeriPal posts was titled "Rant on Terminology," by Patrice Villars, NP.  In the spirit of looking back over our first 10 years, here is the opening paragraph to that post:

News Headlines read: Sen. Edward Kennedy loses battle with cancer. Really, he lost? I thought he died from a malignant brain tumor, an “aggressive” brain tumor. The median survival is less than a year for people for his particular tumor. Kennedy was diagnosed in May of 2008. He lived over 15 months after diagnosis. What a loser. He must not have fought hard enough. Huh? I thought he spent most of his life battling for social and health care reform in America. In this week's GeriPal podcast we take a deeper dive into this issue of language and medicine.  We are joined by guests Anna DeForest, MD, MFA, a resident in Neurology at Yale, and Brian Block, MD, a pulmonary critical care fellow at UCSF.  

Anna recently published a paper in the NEJM describing her reaction to hearing terms like, &…