Page 425 (end of life counseling)

I received several emails over the last few days concerning page 425 of the House Bill on Health Reform, HR 3200, which outlines mandatory end of life "options" counseling.

Technically, it appears on the surface to allow doctors (and other "providers") to charge for the counseling. But, yes, it's mandated counseling and in the wrong hands, it might encourage withholding of care more than some of us would like -- and certainly more that others might like.

Can you imagine a more personal and private subject? The subject should be broached by your family doctor. But it appears that every doctor who sees Medicare patients will be responsible. I can imagine the emotional undertones of different doctors as they recite the standardized language and present the forms to be signed! And then, the counseling will be reported to the Center for Medicare and Medicaid Services, with the appropriate modifying code.

I object to the mandated repeat counseling when someone gets sick, the inclusion in the "Medicare and Me" handbook with language to be formalized by the Secretary and forms for the counseling. I've mentioned before how "hot" an issue this could be, even with my limited exposure to the debate.

I hope that someone with sensitivity is in the Secretary's office, assisting with decisions on the literature and forms.

ABC explains the Obama Administration

ABC News Senior White House Correspondent Jake Tapper has written an article, "When Academic Words Become Political Ammunition," that gives an anonymous "White House official's" rebuttal to the many concerns expressed about President Obama's choices for advisers and "czars" who will affect the shape of health care policies. He attempts to debunk criticisms of the philosophies of Ezekial Emanuel, MD (a bioethicist who is heading the push for control of health care finance and delivery in order to provide universal insurance) and John Holdren, director of the White House's Office of Science and Technology Policy.

The problem is that with Medicare and Medicaid, about half of medical care in this country is already paid for using tax dollars, and we are currently considering expanding tax dollar payment for nearly all health care in the Nation. I disagree with Ezekial Emanuel's position, referenced in the Hastings journal article, "Where Civic Republicanism and Deliberative Democracy Meet," which is linked (in pdf) at Tapper's essay:

Americans fear that if society guarantees certain services as "basic," the range of services guaranteed will expand to include all - or almost all - available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services un- covered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.

In fact, while we are concerned about the amount of taxes that will be imposed, the Tapper essay points out that we are very much afraid that government interference in health care will result in more limitations, so that none of us will be allowed, much less "guaranteed," to seek medical care that will prolong our lives and make us feel better, unless we are seen as members of a group that is more valuable than others. The examples that Dr. Emanuel gives and our observation of the government pre-paid medical care schemes around the world lead us to believe that, the more health care is financed by tax dollars, the more expensive and rationed it becomes.

Academic mind experiments that do not draw a line between what is acceptable and what is condemned by the authors understandably will be interpreted by others as at best, neutral, at worst, in support of condemnable acts.

Congressman Henry Cuellar on Planned Parenthood

Went to this morning’s McQueeney, Texas meeting where Henry Cuellar was met with an overwhelming group of constituents upset over what's happening in Washington, DC.

Rep. Cuellar told us that he voted in favor of Planned Parenthood funding yesterday because they give care to “mothers” and he does everything he can do to support mothers. (I suggested that we go to any PP office today and that I bet no mothers come out of the building.)

The people of Guadalupe County- maybe 100 to 150? - turned out to protest the health bill and tax and cap. There were some tough questions about gas prices and about whether private insurance will survive.

People laughed when Cuellar said the bill is “revenue neutral.”

Believe it or not, the man was adamant that he has good private insurance and that he wants to keep *his* private insurance! Why not put all the government employees on Medicare or the VA (depending on their background). Why do we give and give so that our employees can have better benefits than we can afford?

He constantly talked about organizations and corporations that supported the bills, ignoring that the constituents in front of him do not. He handed out paper after paper (how green is that?) supporting the health bill and tax and cap.

He talked against the Blue Dogs, but did say that he wouldn’t allow Pelosi to bring the bill to a vote by bypassing the Committees.

Myth: doctors take out tonsils needlessly

Then, there's the charge that doctors will needlessly take tonsils out. First, it's unlikely that your Family Physician or Pediatrician does surgery. Second, I don't think the ENT's are getting paid for these anymore, unless they jump through hoops to prove that they're not over-doing it.

AP: In trying to rally support for health care overhaul, Obama described a patient who sees a physician for a sore throat, or a parent who brings in a child with a sore throat.

"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out,'" Obama told a prime-time news conference.

The president added: "Now, that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change — maybe they have allergies. Maybe they have something else that would make a difference."

Video and here.

Obama Press Conference Transcript

The transcript of the press conference is on line at the Washington Post.

However, if you want an annotated version, try this blog.

Thoughts on Obama's health speech July 22, 2009

Why doesn't the President just say that the Executive branch employees in his Administration will get rid of their insurance and go on Medicare???

Not a doggone thing that the President is talking about tonight - except for the taxes, the increased bureaucracies and the requirements that Pharmacy companies discount meds - is in the Bills that are being proposed by the House or the Senate.

The government is not paying for those private insurance costs -- the tax cuts for insurance is not the burden that will break the federal budget.

(And by the way - the White House is the people's house. It's only being used by this man.)

Ann Coulter on government Health Care finance

On the other hand, there's Ann Coulter's take.

Give Ann a chance, here. She makes some very good points.

Addendum -- Including this one:

Now the Democrats want to force us all into one gigantic national health insurance plan that will cover every real and mythical ailment that has a powerful lobby. But if you have a rare medical condition without a lobbying arm, you'll be out of luck.

What works and what doesn't

Art Caplan has written his two cents worth about the health care reform push. Dr. Caplan needs to read the current bills being hashed out in the Senate and the House. The House bill is over 1000 pages. (The expectation is that, like the last 3 Big Bills, the actual final version will appear in the wee hours of the morning, hours before the final vote.)

First, what President Obama is talking about is prepaid chronic care and catastrophic care. These should be addressed separately. Most people can pay for their own physical and for their own blood pressure medicine -- just ask the majority of the Medicare "covered" who saw their deductible go up this year and who hit the "donut hole."

Or ask the veteran who has a job that offers private insurance.

In the '90's, when I was in med school and doing my residency in Family Medicine, the VA was not the stellar government medicine that Art thinks it is today. And the requirements for coverage - who was "service connected" - were constantly being tightened. Men who should have been covered because of their service in WWII and Korea found that the only way to get care was to show up at the ER and wait their turn.

All of the paper work and regulatory hassles - especially the risk of "fraud and abuse," now "fraud, waste and abuse" - that I've faced in practice are the result of Federal laws interfering in normal practice: 1968 then 1974, on through the amendments to the Social Security Act in 1997.

I certainly hope that the powers that be will offer a "basic plan" that is really a basic plan. I know that it cost much less to insure and care for my family back when we had major medical insurance. However, I doubt that the various special interest groups will allow that. The bills mandate that pap smears, mammograms and "preventive services" will be provided at no cost to the patients. No copay, no coinsurance. No deductibles.

This means that we docs will be under pressure to do everything at "preventive visits." However, the House bill mandates qualifiers and diagnostic codes for all services.

Didn't that complicated chart originate from one of the Democratic proponents of health reform?

If you do ask your doctor about the paperwork and hassles, ask them whether they'd rather fight Medicare or United Health.

If Medicare truly has a lower administration cost, it's because laws and regulations shift the burden to your doctor and the hospital social services and patient advocates.

When I run up against a Blue Cross or Humana requirement that I disagree with, I can argue with the Medical Director or even drop their plan and see their patients outside of the plan for cash. However, if I disagree with a Medicare ruling that I can't admit my 82 year old who's falling, has a low potassium level, is running a fever, and has a bladder infection unless he's septic as defined by Medicare, there's no doctor to talk to. There's thousands of pages of regulations each year and that risk of "fraud and abuse."

Another difference - the government is not paying for those private insurance costs. If they will leave us alone, the insurance costs will either cut their growth or price themselves out of business. If the government increases its payment by the plans proposed in the House and the Senate, the costs will simply grow as they have.

These costs will be added to the 23 Trillion dollars our grandkids already owe.

Mayo Clinic calls health care plans bad medicine

I've always said that if the Mayo Clinic docs were so smart, they'd come to Texas where it's warm and they can golf year around (like their patients who visit us from October to April).

Nevertheless, doctors at Minnesota's Mayo Clinic have come out against the current plans for health "reform." They are joined by the US Chamber of Commerce.

And then, of interest to those of us who are pro-life, there's the President's assertion that he will leave the decision to pay for abortion up to the "experts."

The President's history of overturning restrictions on federal funding of abortion and of regulations strengthening the conscience rights of medical professionals does not back up his assertion that his administration will not support abortion by federal health care funding.

How many pro-life doctors will he put on the MedPAC???

Governor Jindal reminds us how FEMA helped flood insurance

You may not be aware that the only way to buy flood insurance is through FEMA, the Federal Emergency Management Agency. In fact, the Agency draws the lines for the Flood Plains and so, decides whether you need flood insurance.

Executive Order 12127

President Carter's 1979 executive order merged many of the separate disaster-related responsibilities into the Federal Emergency Management Agency (FEMA). Among other agencies, FEMA absorbed: the Federal Insurance Administration, the National Fire Prevention and Control Administration, the National Weather Service Community Preparedness Program, the Federal Preparedness Agency of the General Services Administration and the Federal Disaster Assistance Administration activities from HUD. Civil defense responsibilities were also transferred to the new agency from the Defense Department's Defense Civil Preparedness Agency.
John Macy was named as FEMA's first director. Macy emphasized the similarities between natural hazards preparedness and the civil defense activities. FEMA began development of an Integrated Emergency Management System with an all-hazards approach that included "direction, control and warning systems which are common to the full range of emergencies from small isolated events to the ultimate emergency - war."

As we learned in 2005, the centralized bureaucracy is not the most efficient method of responding to the disasters of flooding. (It might have helped if the former Governor had allowed earlier response.)

Governor Jindal discusses possible "bipartisan" health care reform measures, here.

Redefining, Reducing and Rationing Health Care

Peter Singer, in his op-ed for the New York Times this weekend, seems to be unaware of the difference that our mobility in the United States - both in geography and society - can make. We have choices, can call on friends and family and/or gain sympathy of the wider community (as demonstrated by the pink ribbons on so many cars and products) to obtain what we need and sometimes what we want. (Hear those Rolling Stones in the background? )

I don't expect perfect this year, but I'd sure like to have more options than Pelosi, Rangel, Waxman and Kennedy seem to allow. And, like many other Americans, I'd be more reassured if the Speaker and the House Ways and Means Committee would agree to sign up for the "public option" and if Ted Kennedy would accept the same rationing he's proposing for the rest of us. (No Chappaquiddick health care jokes, please - but isn't he aware that he's going to need readmission to the hospital soon? And don't you think the anecdotes he tells are ironic?)

Or, if the President could get his budget report out on time.

However, the AMA has endorsed the House Bill (no number, yet) as unveiled last week, in spite of the fact that the definition of "primary care provider" includes nurse practitioners. The White House immediately began pushing for cuts in physician payments to ensure that there's no deficit. Orszag hinted on TV yesterday that the 20% cut due next year would work just fine.

My letter to the Board of Trustees of the AMA resulted in a reply from Dr. Rohack:
"As noted, there are elements in the bill that will help you as a family physician in Texas. And as fellow Texan {sic}, you know as well as I that leading the nation in the number of uninsured patients is not a proud statistic and having some federal help will be needed for our patients since our Texas legislature continues to pass on opportunities to help them."

(And Texas' economy is relatively stable as our State government is solvent, too, Dr. Rohack.)

I'm not sure how many of you remember the retroactive tax increases passed by Congress and even instituted by IRS rules. But I'm sure that you remember this Congress' threat this year to retroactively tax the bonuses given to AIG employees.

The House "Reform" Bill allows the Secretary of Health and Human Services not only to set what we are paid, but to set the Nation's mandated insurance coverage, premium rates and then the taxes and penalties that are supposed to pay for half the cost of the Bill, all coordinated with the IRS.

The other half will come from proposed savings. That 20% cut in Physician payments from Medicare is going to look awfully attractive to the bureaucrats.

Everyone's income is no safer than the payment your Family Nurse, uh, Doctor may receive under this Bill.

Health Care Reform: Tax and Spend (and abortion on tax dollars)

(Editorial correction: Sermo was not begun by the AMA. It is a private group, possibly funded originally by pharmaceutical companies. But, no one there knew the funding source.)
(The vote is now nearly 11,000, and still against the new plan.)

How about a simple solution to the rising government expenditures for health care: don't "force Congress" (See President Obama's press statement video, here. At 6 minutes 40 seconds, he says "force Congress.") to spend more money!

Or, we could try Biden's plan to spend more so we won't go bankrupt as we bankrupt the insurance companies and increase the numbers of people on government-paid health care and increasing mandates that health care funding cover more and more "benefits."

The AMA started a blog-type website that can only be accessed by licensed physicians in the US. 94% of the 2949 docs who have responded to the poll on that site, Sermo, oppose the AMA's endorsement of the current House plan. 96% say that the AMA does not speak for them. The top concerns that the doctors have include interference in the doctor-patient relationship (34%) and malpractice/tort reform (32%).

I've already sent my request to the AMA Board of Trustees to rescind their endorsement. CBS news reports that

"Separately, the White House urged Speaker Nancy Pelosi to toughen the emerging bill so it will hold down the future increases in Medicare payments to doctors, hospitals and other providers. The request, in a letter from Budget Director Peter Orszag, came one day after Congress' top budget official warned that as drafted, the legislation fails to slow the growth in health care costs nationally."

The House Bill still doesn't have a bill number. It's gone from 300 pages to 600 pages, to the current 1018 pages. It's here http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BillText-071409.pdf

All of the Democrat-controlled committees in the House and the Senate have blocked amendment after amendment that would have limited or blocked taxpayer funding of abortion. This is at the same time that the House Finance Services legislation passed, which will allow tax money to pay for abortions in the District of Columbia!

The House's plan will make it impossible to have private insurance if you don't have it at the time the plan passes and those plans will be restricted from changing, except for adding costly benefits that the House mandates. They won't be able to charge anyone any copays for "preventive services" - well child care, physicals and colonoscopies, etc. These requirements will bankrupt the insurance companies.

Everyone who does not have a plan at the time the House "reform" goes into effect will be forced onto the public plan on day one. If they don't sign up, they pay a fine of 2% of their income - this is in addition to the new employer tax and the new "surcharge" tax on the rich - or as Speaker Pelosi says, "a very few people will help with the revenue stream."

(Cross posted to Comal County GOP blog)

Will you pay for abortions?

One more problem with federal interference in the payment for health care is whether or not Federal tax money will be used to pay for abortions. I've been worrying about what I'd do about my taxes if the law makes me complicit to this extent.

From the Kaiser Foundation:

An ultimatum against using federal money for abortion procedures could reopen the politically treacherous rift over the issue, creating yet another obstacle for congressional Democrats to overcome if they are to achieve their health reform goals, Time reports. "While current versions of the [health reform] legislation do not address the abortion issue at all, late last month 19 anti-abortion Democrats in the House sent a letter to Speaker Nancy Pelosi, warning 'we cannot support any health care reform proposal unless it explicitly excludes abortion from the scope of any government-defined or subsidized health insurance plan.'"

Congress banned spending federal Medicaid dollars on abortions in 1976, and all but 17 states banned paying for the procedures with state Medicaid funds, too. However, as many as 90 percent of private insurers do pay for abortions and the restrictions the legislators are demanding could compromise those benefits. Under one proposal, individuals earning up to $43,000 a year who get subsidies to buy insurance could not purchase a policy that has abortion coverage. "And it would raise all sorts of other questions if insurers were allowed to discriminate among their customers based on whether or not they are using federal dollars to pay for their policies," Time reports.

"Abortion rights advocacy groups are pushing back. On Monday, the National Women's Law Center released a poll of 1,000 likely voters conducted by the Mellman Group indicating that 71% favor including reproductive services such as birth control and abortion as part of health reform," Time reports. "The poll also found that 75% believe an independent commission should determine what medical services are covered among the basic benefits offered under health reform" (Tumulty, 7/8).