I’m getting whiplash. First,they are in, then they are out, then they are in–and now, after all the yelling and defending, they are out again. What? Payment for doctors to provide end of life counseling. From the NYT story:
The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday. The move is an abrupt shift, coming just days after the new policy took effect on Jan. 1. Many doctors and providers of hospice care had praised the regulation, which listed “advance care planning” as one of the services that could be offered in the “annual wellness visit” for Medicare beneficiaries.
Don’t blame me: I said the rule was different from the original legislative proposal–and therefore not a real problem. Blame incompetence–apparently Donald Berwick promulgated the regulation when the proposal had not been included in the original Notice of Proposed Rule Making–which is required so interested parties can comment before the rule is finalized. Duh. But the Times reports the administration is also walking on some chicken feet:
While administration officials cited procedural reasons for changing the rule, it was clear that political concerns were also a factor. The renewed debate over advance care planning threatened to become a distraction to administration officials who were gearing up to defend the health law against attack by the new Republican majority in the House.
They’ll be back, the administration claims. Hopefully, Berwick won’t be once his recess appointment expires at the end of the year.
January 6th, 2011 | 4:26 pm
I think it’s just as well if payment is not made for end-of-life counseling. After all, as we all know, the forms provided for living wills are often biased toward refusing care, including nutrition and hydration, as is the training doctors receive. End-of-life counseling is not a medical treatment, and it involves ethical and even plausibly religious considerations about which doctors have, qua doctors, no special competence. It seems extremely plausible that any end-of-life counseling provided by a doctor alone will involve a bias toward refusal of care, nor do I think there is any particular point in trying to order doctors by some sort of neutrality order not to have this bias. A doctor is a person, not a machine, and if he is being asked to provide counseling it is not per se illegitimate or unprofessional for him to indicate what he thinks is best. It just happens that I think if he indicates this, more patients will feel that they should refuse care which they might not refuse if they had been counseled instead by a priest, pastor, a pro-life advocate from some organization whose literature they receive, or even, for that matter, by a lawyer. End-of-life care decisions are too freighted with non-technical considerations for technical expertise to be considered sufficient qualification for providing counseling. Yet if patients are officially receiving such counseling as a paid service, they are likely to treat the pronouncements of the doctor as oracular and authoritative.
I understand that there is a difficulty if patients really want to know what their doctors think or even if they want to ask technical, medical questions about the effects and risks of certain end-of-life options–it is only fair that the doctor be paid for his time in that case. But if the person is ill, it seems to me that some of that information could be obtained, perhaps by a question here and a question there, at real medical appointments. A late-stage cancer patient goes in for a treatment and checkup by his oncologist and lets it be known ahead of time that he wants to talk to the doctor about the effects of morphine, for example. The appointment will be paid for as a regular visit with the oncologist that he was going to have anyway, and the doctor will be able to answer those questions at that time. In this way the conversations are kept focused and medical in nature, rather than being billed as some sort of comprehensive “end-of-life counseling.”
So I think it is in general a good thing if end-of-life counseling is not treated and reimbursed as a medical expense.