Experts Debunk Health Care Reform Bill's 'Death Panel' Rule
Doctors Agree Health Bill Has No 'Death Panel' Requirement for the Elderly
By KATE SNOW, JOHN GEVER and DAN CHILDS
In Collaboration With MedPage Today
Aug. 11, 2009
Accusations that the health care reform bill now pending in the House of Representatives would use "death panels" to deny care to sick seniors and children with birth defects have taken center stage in the health care debate, giving the Obama administration even more of an uphill climb in getting the measures enacted into law.
But health care experts – even those who do not support the version of the health care reform bill now being discussed – note that these accusations are shocking, inflammatory and incorrect.
At issue is a 10-page section of a 1,000-page House health care reform bill on "advanced care planning consultations." These consultations would reimburse a doctor for talking with a patient once every five years about what kind of care they want near the end of life.
The provisions spurred conservatives, including former New York Lt. Governor Betsy McCaughey, a Republican and now a conservative commentator, to charge that these consultations would ration health care for elderly and "tell them [seniors] how to end their life sooner, how to decline nutrition, how to decline being hydrated, how to go into hospice care."
That led to shouts of "This is euthanasia!" from angry citizens at health care town halls all across the nation hosted by members of the House or Representatives. One person said, "Adolf Hitler called his program the 'Final Solution.' What will we call ours?"
In fact, doctors and supporters say, the intent of the measure is not for doctors to tell patients what to do, but to give doctors more incentives to talk to patients about all of their options.
'Death Panel' Debate: Politics of Distortion?
The provision cited by McCaughey requires only that Medicare cover end-of-life consultations for patients who want it. It does not force clinicians to provide them or patients to undergo them, doctors say.
"Advance care planning has nothing to do with 'rationing care,' and calling it 'death panels' is derogatory and preposterous," said Dr. Marcin Chwistek, an attending physician in oncology with the pain and palliative care program at Fox Chase Cancer Center in Philadelphia. "I sincerely hope that such consultations will initiate what has been long due in the American health care system -- a thoughtful care that results from careful discussions and planning between patients and their doctors, as opposed to a care that is chaotic, based on assumptions, and frequently in conflict with patients' deep held values."
Currently, Medicare doesn't pay for consultations focusing on end-of-life care. Under the bill, Medicare beneficiaries would have them covered every five years, or more frequently if the individual's clinical condition deteriorates.
In addition to the coverage expansion, the bill also calls on the Medicare system to adopt quality standards for end-of-life care.
The AARP defended the legislation too. In a statement, the powerful seniors' lobbying group said McCaughey's charges were "rife with gross -- and even cruel – distortions... McCaughey's criticism misinterprets legislation that would actually help empower individuals and doctors to make their own choices on end-of-life care."
"Right now it seems there is an intentional effort to distort what's in the legislation and that's confusing the public debate," AARP executive vice president of policy John Rother said.
In La Crosse, Wis., such "end-of-life consultations" are already common because of a program put in place by a local hospital.
As a result of these consultations, La Crosse resident Ann Kottnaur said she now knows that her mother Margaret, who has Parkinson's disease and dementia, would rather die at home than in a nursing home.
"By the time we completed it, her health had started to fail," Kottnaur said of the end-of-life care consultations. "So we knew from a long time ago that that was her wish," Kottnaur said.
If La Crosse is any example, people do often choose limits on care for their final months. And the fact is, that saves money. In La Crosse, medical spending in the final year of life averages $18,000. The national average is $25,000.
'Death Panel' Discussion Spreads
The controversy apparently began when McCaughey, appearing on the radio talk program "The Fred Thompson Show" on July 16, charged that this provision in the House bill would require everyone in the Medicare system to undergo mandatory end-of-life counseling every five years.
"This is a vicious assault on elderly people, all to do what's in society's best interest, or your family's best, and cut your life short," McCaughey said.
On Friday, former Alaska Governor and Republican vice presidential candidate Sarah Palin went further, alleging that the session would amount to "death panels" and would pass judgment not only on older people's right to health care, but on others' as well.
"The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care. Such a system is downright evil," Palin wrote on her Facebook page.
And House Minority Leader John Boehner (R-Ohio) chimed in a week later, saying the bill would "start us down a treacherous path toward government-encouraged euthanasia if enacted into law."
Melody Barnes, director of President Obama's Domestic Policy Council, denounced the Republican charges as baseless propaganda.
"We've seen these antics too many times before, when people try to scare the public," she said in a video statement on the White House web site.
"This provision will allow people to access information about getting a living will. There's absolutely nothing mandatory about this," she said."It will actually empower people… to have conversations with their doctors where they can get accurate information if they choose to do so."
Rep. Earl Blumenauer (D-Ore.), who helped author the provision, echoed Barnes's comments. "There's nothing in this legislation that would force people to have consultations. There's nothing that would force them to sign advance directives. It's not going to choose a health care professional by the government and force it on them," he said on the House floor.
Escaping 'Death Panel' Rhetoric: The Real Issues
ABC News Chief Medical Editor Dr. Timothy Johnson, who says he believes the provisions for end of life care discussions are a good idea, said that– there are other aspects of the potential legislation that deserve further scrutiny, depending on the details involved. One of these aspects, he noted, is the Physician's Quality Reporting Initiative for end of life care, which will "measure both the creation of and adherence to orders for life sustaining treatment" – a facet of the plan that he said could turn out to be logistically difficult and "maybe has too much the flavor of reporting back to big government or big brother."
Another issue, Dr. Johnson noted, is the fact that payments to doctors for such counseling are tied to whether or not the patient and family actually follows through with the end-of-life care plan set forth during a consultation. If a patient were to change his or her mind, in other words, the doctor would not be reimbursed for the counseling provided.
Reform Opponents Still Agree 'Death Panel' Label Ludicrous
"I doubt most physicians would pressure a patient or family to adhere to an end-of-life care plan just so they could qualify for a bonus, but why link payment to something like this?" he asked.
Still, Johnson noted, "these kinds of questions should not scotch the effort to increase such services. We spend far too much money and emotional resources prolonging death versus supporting life during terminal care in this country."
But there is also the issue of cost, and whether in fact end of life care adds significantly to those costs. Varying estimates place the cost to Medicare for the last six months of life at 25 percent to 50 percent. So, many supporters of the provision argue that reducing these consultations included in the bill could save money. However, Joseph White, director of the Center for Policy Studies at Case Western Reserve University in Cleveland said the bill's defenders were wrong in suggesting that such consultations would produce cost savings.
"The share of Medicare spending that goes to patients in their last year of life has not grown over the past four decades or so," White said. "That means costs at the end of life are not the driver of cost increases... The whole idea that costs go up particularly because we keep proliferating services to old people at the end of their lives, compared to services to anyone else, is simply wrong. False."
Even a longtime supporter of Republican approaches to health care backed the provision in the bill. Gail Wilensky, who headed the Health Care Financing Administration and chaired the Medicare Payment Advisory Commission during President George Bush's administration in the early 90s, said:
"There are plenty of things not to like about 'Obama-care,'" she said. "This is not one of them."