Health policy

IPAB: Fix It, Don’t Repeal It

August 8th, 2011 | 1 Comment | Source: Commentary

In recent weeks, several Democrats and some health reform advocates including the AMA have joined Republicans in calling for a repeal of provisions in the new health law that create the Independent Payment Advisory Board (IPAB). For these people, IPAB represents the worst aspects of the new law–an unelected, centralized planning authority empowered by government to make decisions about the peoples’ health care. Arbitrary cuts to providers, short-sighted decisions that stifle innovation and rationing of care are sure to follow, they claim.

While it’s true that the rules governing IPAB are flawed and should be fixed, eliminating IPAB altogether would be a mistake.

Created by the Affordable Care Act, IPAB is a fundamental part of the law’s plan to control health care cost escalations. The law contemplates that each of the Board’s 15 members would be appointed to a 6-year term by the president. Members are to include providers, health policy and public health experts, and consumer representatives. Each would have to be confirmed by Congress, much like Supreme Court justices. And unlike a frightening, wizard-like bureaucrat operating behind a curtain-as critics would have you believe-the IPAB chairperson would be required to appear before any committee of Congress that desires a hearing, just as the President’s cabinet members are required to do.

IPAB’s mandate would be to recommend ways to prevent excessive escalations in Medicare expenditures. Specifically, whenever these costs grow faster than targets established by the Affordable Care Act, IPAB would propose ways to reduce Medicare spending by up to 1.5%. When that happens, Congress can either approve those recommendations, develop alternatives with the same impact, or simply allow Medicare costs to accelerate. In the last instance, a 60% majority of the Senate would be required to overrule the IPAB recommendation.

Some sort of cost-governing approach is mandatory, because we want to offer comprehensive coverage to Medicare beneficiaries within some reasonable cost structure, and because Congress has shown no inclination to do so, for example by enacting quality- and efficiency-based payment models. As Jonathan Cohn points out, Congress is unlikely to do this going forward, because its members are heavily influenced by lobbyists whose job it is to maintain the lucrative status quo. IPAB members, shielded as they would be from such influences but still wholly accountable to Congress, may well succeed where lawmakers have not. (more…)


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The Federal Deficit and the Health of American Citizens

July 12th, 2011 | No Comments | Source: Commentary

It was nice while it lasted, but the brief surge in optimism surrounding debt-reduction negotiations died Sunday, when Speaker of the House John Boehner announced that his party wouldn’t swallow President Obama’s proposed $800 billion tax increase as part of a package designed to save $4 trillion.

If nothing else, the collapse of the negotiations made it clear that Republicans don’t care about the deficit per se. What they care about is cutting federal spending and taxes, and they’ll do that even if it means partially dismantling popular entitlement programs in the process.

One would think the GOP would have gotten the message that this was a bad idea when a reliably Republican district in upstate New York elected Democrat Kathy Hochul to fill a vacant House seat in a special election last month. Hochul’s entire campaign revolved around preserving Medicare and denouncing a plan by Republican Paul Ryan to transform it into a voucher program, cutting benefits in the process.

In fact the draconian spending cuts envisioned by GOP deficit hawks would impact the health of American citizens far more profoundly than the Ryan plan envisions.

That’s because, as I argued here and here, public health isn’t a medical problem at all. It is a socioeconomic one, and cuts to many programs other than those proposed for our health entitlement programs will affect national well-being and health as a result.

Take Canada for example. That country provides universal, free access to health services for all citizens. If poor access to health care (a problem that would be exacerbated by GOP cuts to health entitlement programs) was the only factor driving poor health outcomes, then we shouldn’t see poor, or less educated people experiencing poor outcomes in Canada. But these differences do exist, in spades. In a recent study of 15,000 Canadian adults for example, participants in the lowest income group were nearly 3 times more likely to die of any cause than those in the highest income group. They were also more likely to have diabetes, high blood pressure, cancer, cataracts and many other conditions. The study revealed similar disparities when participants were stratified by educational level. (more…)


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HHS Serves Up Prevention ‘Lite’

June 29th, 2011 | No Comments | Source: Commentary

In the 1993 film Groundhog Day, Bill Murray plays a TV weatherman who finds himself trapped in a do-loop, covering the numbingly boring display of Punxutawney Phil, over and over again.

Forgive those of us who follow news from the Department of Health and Human Services for feeling like Bill Murray in that movie.

Last month, HHS released an action plan to reduce racial disparities in health care. The plan called for new care models, more service delivery sites, a beefed-up health and human services workforce, and targeted efforts to reduce cardiovascular disease, childhood obesity and other scourges of minority populations.

Remarkably however, the plan came with no funding. Apparently, it was supposed to prompt agencies within HHS to assure that their own internal plans were aligned with the effort to reduce racial disparities. Worse yet, the plan involved only HHS itself. In effect, it assumed that a ‘medical model’ can solve racial disparities in health care. However as I argued here, these disparities aren’t about health, at all. They are about socioeconomic status, and HHS can’t fix that by itself.

Solving the problem of racial disparities in health care clearly requires input from many branches of government, including those involved with education, urban planning, transportation and more, in addition to HHS.

When it was all said and done, the HHS plan came off looking like a political stunt by the Obama administration. While the administration probably does want to fund a bona fide effort to reduce racial disparities, today’s incessant (and appropriate) focus on deficit reduction forced the administration to release a plan with no teeth. It isn’t going to make a dent in the problem.

“Oops!…I Did It Again.” Britney Spears

Now barely a month later, HHS has pulled the same stunt again! With considerable fanfare, it released something called a National Prevention Strategy. It too, is not funded.

To its credit, the National Prevention Strategy does involve multiple agencies. “If we want to achieve our goals and make a real change in the health of our nation, it can’t just be one department doing the work. If we’re going to serve healthier school lunches, we need to work with the departments of Agriculture and Education … If we want to create healthier homes, we need to work with the Department of Housing and Urban Development,” HHS Secretary Sebelius explained. (more…)



The Affordable Care Act and the PCP Manpower Shortage

June 20th, 2011 | No Comments | Source: Commentary

The Affordable Care Act is the most important piece of federal health care legislation since the Social Security Act created Medicare in 1965. It assures that 32 million Americans will gain access to health insurance for the first time. But who will care for these people?

The flood of newly insured people will create a surge in demand for physician services. By 2015—one year after the major provisions of the ACA take effect—the US will have 63,000 fewer physicians than it needs to meet this demand, according to the Association of American Medical Colleges.

The shortfall will hurt everyone, but its impact will be devastating for medically underserved populations where finding a doctor is already difficult. This includes nearly 20% of the US population.

Unfortunately, the ACA doesn’t include a manpower plan that sufficiently accommodates the surge. The most optimistic projections suggest it will add 500 or so physicians per year to the workforce during the next decade, and even that modest growth has recently come under attack by House Republicans.

Two weeks ago, the GOP-controlled House voted 234 to 185 to eliminate $230 million in mandatory ACA funding for the creation of a new teaching model for residents in primary care. The model is based around “teaching health centers,” which would be placed in medically underserved areas and mirror the practice environment residents will enter upon completion of their training.

The GOP isn’t against the new training model, but objects to the automatic, mandatory payouts associated with it. They propose that funding for the manpower initiative should be subjected to votes each year during Congress’ annual appropriations process. “It’s time to move these programs back to the discretion of this Congress,” Marsha Blackburn (R-Tenn.) explained, referring to it as one of many  “slush funds” provided by a debt-ridden federal government. (more…)


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The HHS Plan to Reduce Racial Disparities in Health Care

May 26th, 2011 | No Comments | Source: Commentary

Twelve years after our nation began a serious effort to reduce racial disparities in health care, minorities in our country are still less likely to get the preventive care they need and more likely to suffer from serious illnesses. And when they get sick, racial minorities are still less likely to have access to quality health care.

To progress matters, the Department of Health and Human Services (HHS) has recently released an action plan. The plan calls for development of new care models and more service delivery sites. It bolsters the nation’s health and human services workforce through a pipeline program that channels people from underserved communities into public health and biomedical sciences careers. There are targeted efforts to reduce cardiovascular disease, childhood obesity, tobacco-related diseases, flu and asthma. And there are plans to improve health data collection and increase outcomes research.

Strengths of the Plan
As we described last week, the problem of racial disparities in health care is exceedingly complex. Efforts to address it must feature a broad, multifaceted approach if they are to have any chance for success. The strength of the HHS plan is that it contemplates just such an approach.  The plan should trigger useful activity at National Institutes of Health, the Centers for Disease Control, the Health Research and Services Administration, the Agency for Healthcare Research and Quality, the Indian Health Service and other agencies as well. Cross-agency collaboration of the sort envisioned by HHS is likely to generate effective outreach and preventive programs and more capable oversight of such programs.

A narrower plan—for example, one that focused solely on providing insurance to those who don’t have it—would have a surprisingly small impact on racial disparities.

Take Canada for example, a country that has universal, free access to health services. If poor access was primarily responsible for disparities in health care, then disparities shouldn’t exist in Canada.

However a recent study by David Alter and colleagues shows unequivocally that disparities do exist there. In their prospective study of 15,000 Canadian adults, Alter’s team showed that participants in the lowest income group were nearly 3 times more likely to die of any cause than those in the highest income group. They were also more likely to have diabetes, high blood pressure, cancer, cataracts and many other conditions. (more…)



Racial Disparities in Health Care: The Hundred Years’ War

May 18th, 2011 | No Comments | Source: Commentary

It was 1999 when the Federal government first acknowledged our nation had a problem with race and health care. That year, Congress tasked the Institute of Medicine to study the matter, and the resulting report was not good. Minorities were in poor health and receiving inferior care, the report said. They were less likely to receive bypass surgery, kidney transplants and dialysis. If they had diabetes, they were more likely to undergo amputations, meaning their disease had been poorly controlled. And there was a lot more where that came from.

The IOM report was a call to action. In subsequent years, lawmakers crafted policies and established goals for improvement. Federal and state governments and numerous foundations set aside billions to fund projects. Health services researchers expanded their efforts to study the problem.

Twelve years later, we have something to show for the effort. Steep declines in the prevalence of cigarette smoking among African Americans have narrowed the gap in lung cancer death rates between them and whites, for example. Inner city kids have better food choices at school. The 3-decade rise in obesity rates, steepest among minorities, has leveled off.

Nevertheless, racial disparities persist across the widest possible range of health services and disease states in our country. The overall death rate from cancer is 24% higher for African-Americans than white people. The racial gap in colorectal cancer mortality has widened since the 1980s. African Americans with diabetes experienced declines in recommended foot, eye, and blood glucose testing between 2002-2007.

Why is this problem so hard to solve?
The reason is that the problem is exceedingly complex. Hundreds of factors contribute to racial disparities in health care. Progress on just a few of them is therefore unlikely to move the needle much (which isn’t to say we shouldn’t try!). The key contributing factors are these:

Identifying Target Populations-Studies of racial disparities in health care rely fundamentally on tools that classify people by race. These tools are notoriously imprecise. Most of them classify all people whose family immigrated from a country that was once considered part of the Spanish empire as “Hispanic,” for example.  This means people of Panamanian, Mexican and Venezuelan descent are grouped together (to name but 3 countries).

The resulting “Hispanic population” in studies of health disparities is actually a polyglot of culturally-driven lifestyle choices, tendencies to seek care from physicians, and dozens more behaviors that impact health. This heterogeneity severely undermines the value of information obtained from the studies.

The Genetics Don’t Work: The genes responsible for phenotypic traits that forensic pathologists and anthropologists use to study race aren’t the same ones that govern how sodium-potassium ATP pumps work (and how they impact hypertension risk, for example). They have nothing to do with the genes that govern the body’s tendencies to store fat and establish a basal metabolic rate (and how they impact obesity risk). In fact race is largely a red herring in the search for genetic links to cardiovascular disease, cancer and other conditions that kill US minorities disproportionately . (more…)


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How Obama Would Cut Medicare and Medicaid

April 14th, 2011 | 2 Comments | Source: MedPageToday, Washington Post

Yesterday, President Obama finally entered the debate about the national debt with a proposal to reduce US government borrowing by $4 trillion over the next 12 years. The proposal called for higher taxes on rich folks as well as deep cuts in military and domestic spending, including Medicare and Medicaid.

But unlike an earlier proposal by Representative Paul Ryan (R-Wisconsin), the Big O’s plan did not include making fundamental changes to the 2 US health entitlement programs, nor did it scale back the primary objective of the health reform law passed last year (the Affordable Care Act, or ACA), which is to provide health-care coverage for millions of uninsured Americans.

“We don’t have to choose between a future of spiraling debt and one where we forfeit investments in our people and our country,” he said. “To meet our fiscal challenge, we will need to make reforms. We will all need to make sacrifices. But we do not have to sacrifice the America we believe in. And as long as I’m president, we won’t.”

Ryan’s plan calls for Medicare beneficiaries to select from a pool of private insurance programs, and for the feds to pay a fixed amount of premium funds to the insurer chosen by each beneficiary. Additional costs would have to be borne by the beneficiary.

The president’s plan calls for $480 billion in cuts to Medicare and Medicaid by 2023, and a beefed-up role for the Independent Payment Advisory Board (IPAB), the new independent panel formed by the ACA as a watchdog against health cost escalations.

Responding to the Ryan proposal, Obama said, “Let me be absolutely clear: I will preserve these healthcare programs as a promise we make to each other in this society. I will not allow Medicare to become a voucher program that leaves seniors at the mercy of the insurance industry, with a shrinking benefit to pay for rising costs.”

The cornerstone of Obama’s proposal was a provision that empowers the IPAB to make cost reduction recommendations to Congress in the event that Medicare costs grow faster than the per-capita Gross Domestic Product plus 1%. The provision requires that these recommendations must not impede beneficiaries’ access to appropriate services. Now, Congress wouldn’t have to follow the advice from the IPAB. It could institute its own solution so long as it achieved the target reductions. In the event that Congress failed to act however, the Secretary of HHS would be required to develop and implement a plan that hit the target. (more…)



Are Habilitative Services Part of “Essential Care”?

April 1st, 2011 | 1 Comment | Source: Commentary

One of the great challenges facing the folks who have been tasked to implement the Big O’s health care law is defining “essential benefits,” the core medical services that insurers must cover.

Despite its voluminous nature, the law is remarkably vague in this regard. It does identify 10 care categories that health plans must provide to consumers who use federally-funded health insurance exchanges to select a plan, but the categories and associated lists aren’t comprehensive or specific (the categories appear at the end of this post).

The Institute of Medicine has been tasked to flesh out the lists of required services. It has begun work amid a frenzy of lobbying by private insurers and consumer groups. Habilitative services are one contentious area, and they illustrate the challenges faced by the IOM. Unlike rehabilitative services which help people recover lost skills, habilitative services help them acquire new ones.

Habilitative services can help autistic children improve language skills, or those with cerebral palsy learn to walk. They can also help a person with schizophrenia improve his social skills.

These services tend to be expensive because they are provided over several years. Insurers tend not to cover them. Their justification (when one is given) is that they are experimental or educational.

How expensive can habilitative services be? The consultancy Oliver Wyman estimated they can run in excess of $60,000 per year for younger children. These numbers drop substantially once the child becomes more independent. (more…)



Health Wonk Review: Spring Training Edition

March 17th, 2011 | 3 Comments | Source: Commentary

Spring training 2011 is in full swing. With baseball’s regular season just 2 weeks away, pitchers are lengthening their starts and adding curveballs to the mix. Promising, but lamentably green prospects are being reassigned to Triple A. And word has it that Mariano Rivera is preparing to throw an inning or two, just to be sure his 4-seamer is game-ready before opening day.

People have said that Baseball is Life. That may be stretching it for folks not named Yogi, but surely the game holds lessons for us all…even health policy wonks! Before we highlight the top submissions to this week’s HWR, let’s review some of these lessons:

Lesson 1: People Will Believe Anything
Somewhere this spring, a local sports writer opined that the kid who touched 98 in the 6th inning of a Cactus League game is the next Tim Lincecum, even though he has never recorded a regular-season out above Double A. Another said this year’s Phillies’ rotation will match the prodigious ‘71 Orioles quartet of Cuellar, McNally, Palmer and Dobson. Others claimed that A.J. Burnett will win 20 this year, and that Vlad Guerrero (whose gait is reminiscent of the Tin Man in Wizard of Oz) will steal 20 bases.

And people believe it!

During the epic health reform debate of 2009-2010, Democrats tried to include provisions which authorized payments to physicians for time spent helping Medicare patients prepare living wills. But Sarah Palin claimed those provisions allowed the government to create “death panels,” and John Boehner warned that they would “start us down a treacherous path toward government-encouraged euthanasia.”

People believed that, too!

To this day, an astounding 30% of elderly Americans believe the new health law empowers government panels to make end-of-life decisions for Medicare beneficiaries.

Lesson 2: Sometimes You Get a Do-Over, Sometimes You Don’t
Umpire Jim Joyce robbed Tigers pitcher Armando Galarraga of a perfect game last year when he blew a call on what should have been the last out of the game. Although Joyce later admitted his mistake, there are no do-overs in baseball. The pitcher’s chance to make history was gone forever.

Meanwhile, GOP-appointed Federal District Judge Robert Vinson decided in January that since he found one provision of the Big O’s health law to be unconstitutional, he might as well trash the whole deal. The decision threatened to disrupt planning in 50 states and confused the bejesus out of the American public. But unlike baseball, the US judicial system does permit do-overs…sort of. Two weeks ago, Vinson issued a stay of his own ruling, effectively allowing the law to stand pending an appeal to the Supreme Court.

Galarraga would be immortal if Joyce could have done that!

Go figure. Anyway, the Yankees will rise again in 2011 (believe me!) and finally, thanks to the HWR All-Stars who contributed posts for this week’s edition. Here is the formidable line-up:

The Sluggers (Health Policy)
For his post on the Forbes website, Avik Roy produced a chart showing results from the Health Tracking Study Physician Survey. The chart confirms that physicians refuse to accept Medicaid patients at rates that far exceed those who are covered by Medicare and private insurance. Roy suggests this problem is responsible for poor clinical outcomes seen in Medicaid beneficiaries.

Between innings, Roy should have a beer with Austin Frakt, who pretty much blows-up the premise that Medicaid recipients receive poor quality health care. In a post for the Incidental Economist, Frakt shows that studies used to support the premise reveal an association between Medicaid and individuals with poor health… it’s their poor health, Frakt says, that is driving poor outcomes in this population, not lousy doctors or poorly designed care systems.

Now that President Obama has decided to support Wyden-Brown, disaffected governors and state legislators can craft PPACA alternatives that are more to their liking, writes Joe Paduda over at Managed Care Matters. According to Paduda, if Republicans actually have a better approach to the problems of health care access and cost, they are going to win big in 2012.

For his part, John Goodman predicts that the PPACA will encourage many patients and providers to opt-out of the third-party payer system. Posting on his own Health Policy Blog, Goodman visualizes a major shift toward concierge-type services and the creation of new markets in which providers compete for patients on price, quality and amenities.

Neil Versel is a huge fan of Don Berwick, but he deplores the way President Obama attempted to install the Quality Don as a recess appointment to head CMS in July, 2010. According to Versel, the underhanded nature of the appointment provided fodder for “uninformed ideologues and assorted nut jobs to attack Obama’s healthcare reform efforts.” Versel’s blog is Meaningful HIT News.

Over at BNet Healthcare, Ken Terry observes an accelerating trend in which insurers and providers are partnering to create Accountable Care Organizations. Terry believes the 2 groups actually can cooperate to form such organizations, and cites several recent acquisitions and partnerships which appear to support his position.

Marsha Gold has followed the Medicare Advantage program and its predecessors for years. In her post on the Health Affairs Blog, she summarizes the program and describes how its beneficiaries will be affected by the PPACA.

In a post for his Health Business Blog, David Williams reminds us that many folks want to overturn new rules restricting Flexible Spending Accounts. Williams ups the ante a bit by suggesting that we eliminate FSAs altogether, and get rid of those pesky tax deductions for health insurance while we’re at it.

David Kindig reviews the implications of Wisconsin Governor Scott Walker’s plan to eliminate the state’s $3.6 billion dollar deficit. Kindig argues that some of Walker’s proposed cuts (including reducing Medicaid eligibility) will have serious health implications for people in his state. His post appears at Improving Population Health.

The Lucidicus Project’s Jared Rhoads reacts to presentations he heard at the TEDxDartmouth 2011 conference. After hearing Al Mulley’s familiar argument that our health system needs to adjust more effectively to consumer preferences, Rhoads doesn’t believe we can pull it off.

Reconciling state and federal laws can be difficult, and according to Louise Norris of the Colorado Health Insurance Insider, Health Reimbursement Arrangements (HRAs) are a particularly nettlesome case-in-point in her home state. Her post clarifies the situation, thankfully.

The Starters (Providers)
Roy Poses describes how physicians who are employed by corporations can be pressured to put the corporations’ economic interests ahead of their patients’ interests. Writing for Health Care Renewal, Poses argues that the primary means of corporate control includes restrictive covenants in contracts that have been signed by naive physicians, or signed by physicians under duress.

The PPACA will eventually generate a huge increase in the number of ER visits, according to Amer Kaissi. He argues that better coordination between ER and primary care doctors will be required to address the coming deluge, and offers a roadmap for this effort. Kaissi posts on Healthcare Hacks.

Julie Ferguson of Workers Comp Insider writes that nurses, nurses’ aides and paramedics are facing a rising tide of on-the-job violence. In fact according to Ferguson, only police and correctional officers experience higher rates of on-the-job assaults. Ferguson explores whether this is emblematic of a dysfunctional health system or just a sign of the times.

Liz Borkowski reminds us that while palliative care teams can reduce costs associated with the care of seriously ill hospitalized patients, most people who are eligible for these services don’t receive them. Borkowski, who posts at The Pump Handle, concludes that we have to do more to encourage utilization of these teams.

On The Health Care Blog, Matthew Holt posts an interview with JD Kleinke concerning the latter’s new novel, Catching Babies. Holt describes the book as a “tour de force of health policy and medical soap opera–Health Affairs meets Grey’s Anatomy–wrapped up in the complex world of childbirth.”

The Closers (Quality and Safety)
There is limited evidence to support claims that pay for performance programs improve quality and reduce the costs of health care, according to Jason Shafrin, who posts on The Healthcare Economist. Shafrin reviews Massachusetts’ pioneering P4P program and several other ones that failed to improve care.

Jaan Sidorov laments that a one-size-fits-all approach to health care—characterized by guidelines and decision support—is woefully behind sociotechnical trends that make “mass personalization” possible. Writing for Disease Management Care Blog, Sidorov argues that those who embrace the latter approach (by tailoring treatments based on the health status, preferences and values of individual patients, for example) will win in the marketplace.

At The John A. Hartford Foundation Blog, Chris Langston discusses the problem of overmedicating the elderly. He reviews a study in which 42% of the Indiana Medicaid population who live in nursing homes received at least one “potentially inappropriate medication.” Not surprisingly, these patients had worse health outcomes.

-Seventh Inning Stretch-
Famed HWR Contributor Argues Against a Key Policy Decision:


The Base-Stealers (Health IT)
Many CEOs and CIOs believe that their healthcare IT systems are secure because they “use SSL encryption” or “have a firewall.” That’s not the case, according to The Healthcare IT Guy, Shahid N. Shah. Shah offers a list of questions that executives can use in order to assure their systems really are secure.

Walking through the palatial vendor displays at this year’s HIMSS conference, Anticlue blogger Elyse Nielsen heard surprisingly little buzz about “the cloud.” In her post, Nielsen explains why this was the case, and opines that it won’t be long before the buzz picks-up.

The Slick Fielders (Pharmaceuticals)
Over at Nuts for Healthcare, Jeffrey Seguritan wonders what things would be like if drugs and their makers were forced to endure the same mano-a-mano competition that makes the NCAA basketball tournament such a good watch. Although the FDA does not require comparative trials like this before green-lighting drugs, Seguritan reviews a few such trials that are actually underway.

The Five-Tool Guys (Media)
Lately, health media watchdog Gary Schwitzer has focused on instances in which press releases drive what we call “news” in health care. In a pair of posts on his HealthNewsReview Blog (here and here), Schwitzer warns that when this happens, independently vetted journalism may not have taken place. 

The Stud Prospects (Consumerism)
Employers and health plans continually seek ways to contain health care costs. According to Dave Kerrigan, limiting the size of provider networks is a powerful and potentially beneficial tool in this regard. Kerrigan’s post appears on A Musing Healthcare Blog.

The Rabid Fans
Nobody is immune from DrRich’s sharp-tongued post on The Covert Rationing Blog. DrRich skewers, in no particular order, lying doctors, the right-wing media, the left-wing media, and quite possibly my Aunt Millie as well. We’re not sure what DrRich is for, but we know what he’s against, and it’s just about everything.

“Unions get waivers,” the InsureBlog’s Bob Vineyard exclaims. “Campaign contributors get waivers. Business owners and states get waivers. Why should consumers be left out?” In his post, Vineyard points out that some Michigan Representative wants to give consumers the right to opt out of “Obamacrap.” Obamacrap? Really? Obamacrap?

Whatever. Two weeks from today, Jason Shafrin hosts the Health Wonk Review over at the Healthcare Economist. Good luck Jason, and thanks to the all-stars who contributed to today’s edition!


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Should You Have a Living Will?

February 7th, 2011 | 1 Comment | Source: NEJM, NY Times

A living will is a legal document that enables you to specify your preferences about end-of-life care at a time when you are clear of mind and perfectly able to do so. The document usually covers things like whether you want breathing machines and tube feedings to be used to prolong your life if you have a terminal illness, whether you want providers to attempt resuscitation in the event you are terminally ill and stop breathing, and so on.

The living will avoids confusion because your family members and caregivers will know how you feel about such situations even if you can’t express your feelings at the time they actually happen.

The Case For Living Wills: The vast majority of health care providers, especially those who frequently care for patients with terminal illness, feel quite strongly that their patients should complete a living will, no matter how uncomfortable that process may be.

Numerous scientific studies support this position. For example, in an April 2010 study in the New England Journal of Medicine, scientists found that nearly 30% of all elderly Americans did in fact encounter situations near the end of their lives when these documents would have helped assure they received the care they wanted.

Shortly before that study was published, a  separate study showed that advance care planning improved “end-of-life care and patient and family satisfaction, and reduced stress, anxiety and depression in surviving relatives.”

And before that one appeared, a third one revealed that “end-of-life discussions between doctor and patient helped ensure that one got the care one wanted,” and therefore “protected patient autonomy.”

Recent Political History of the Living Will: These and other studies support the Obama administration’s longstanding efforts to pay physicians for time spent helping Medicare patients develop living wills and other forms of advance directives.

During the epic health reform debate of 2009-2010, House Democrats attempted to include provisions authorizing such payments in the evolving legislation. However, the effort fell prey to scurrilous attacks by Sarah Palin, House Minority leader John Boehner and others. Memorably, Palin said the provisions allowed the government to create “death panels,” of all things. For his part, Boehner claimed the provisions would “start us down a treacherous path toward government-encouraged euthanasia.” (more…)



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