Posted by Ellen Lash
Last year, Medicare paid $55 billion just for doctor and hospital bills during the last two months of patients' lives. That's a lot of money, especially when considering the estimate that 20 – 30% of these interventions and expenses may have had no meaningful impact. You may think that these potential cost-savings should have been a "no-brainer" for Congress to address as part of the extensive debate about health care reform last year, but alas, you would be mistaken. Instead, a proposal to encourage end-of-life planning was dropped from the legislation in response to Republican arguments that the Democrats would convene "death panels" as a means for the government to cut off care for the critically ill.
I was briefly thrilled to learn that the Obama Administration was able to achieve through regulation what couldn't be achieved through health care legislation because of the political firestorm over "death panels." The final version of the health care legislation authorized Medicare coverage of yearly physical examinations (wellness visits). As part of that annual visit, under a new regulation that was to be effective January 1, 2011, Medicare was set to reimburse physicians to have conversations with their patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.
It was an encouraging start to a rational approach to encourage end-of-life planning discussions between a patient and his/her doctor. However, on January 5, the Obama administration reversed their position, stating that they would revise the language in the regulation to remove any references to end-of-life planning. Procedural problems were cited as the reason for the change, but there is little doubt that political reasons played into this position change as well. Republicans in the House are planning to make good on their promise to step up attempts to repeal the recently enacted health care reform legislation when the 112th Congress convenes on January 12. Even though the outright repeal of the legislation would most likely meet stiff opposition in the Senate, where Democrats still hold a small majority, there is no doubt that a battle will ensue. Perhaps the Obama administration decided that to bring end-of-life issues back into play at this political juncture would be too distracting.
This is a set back, but certainly not the end of the discussion.
Dr. Atul Gawande, a surgeon at Brigham and Women's Hospital and writer for the New Yorker, wrote movingly in an article entitled "Letting Go" in the August 2, 2010 New Yorker about the difficulties medical professionals face when deciding when to stop medical interventions and focus instead on improving the quality of the final days of life. Gawande believes that medical professionals need to focus on how to help dying patients achieve what is most important to them at the end of their lives… things like being with friends and family, spending time doing what we care about instead of taking treatments that cause more suffering, being able to keep our sense of humor, being able to keep our dignity.
To generalize, physicians do not find it easy to have these conversations with their patients, whether they are reimbursed for it nor not. So instead of worrying about "death panels" and regulations, all of us should be identifying what our needs are at the end-of-life, other than prolonging it without quality or meaning. And make sure to tell your family, friends, and physician what's important to you.
As the Director of Healthcare Operations at JF&CS, I oversee our VNA, which provides services to homebound elders after a hospital stay or during an illness. These services are covered by Medicare and other insurances, so I am very interested in the topic of health care reform and what the impact of changes in the health care delivery system will mean for our clients and how we care for them.
Ellen Lash, who received her BA in Healthcare Administration from Stonehill College, has worked in the healthcare industry for more than thirty years. Her particular expertise is in home care administration, with experience in both the for-profit and nonprofit sectors. She has been with JF&CS since 1995 and has been the director of our home health and home care programs since 2005.