America's end-of-life care system is largely broken

 
America's end-of-life care system is largely broken
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I distinctly remember when Sarah Palin was called a liar, a fear monger and a lunatic for saying that Obama Care would lead to death panels. Once again, we find out that Sarah was dead right. Pardon the pun.

Remember what Barack Hussein Obama said: "Sometimes it would be better if you just have Grandma 'take the pill'." Mmmm, Mmmm, Mmmm.

As New York Times report:

The country’s system for handling end-of-life care is largely broken and should be overhauled at almost every level, a national panel concluded in a report released on Wednesday.

The 21-member nonpartisan committee, appointed by the Institute of Medicine, the independent research arm of the National Academy of Sciences, called for sweeping change.

“The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” said David M. Walker, a Republican and a former United States comptroller general, who was a chairman of the panel. “The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly.”

Many of the report’s recommendations could be accomplished without legislation. For example, the panel urged insurers to reimburse health care providers for conversations with patients on advance care planning. Medicare, which covers 50 million Americans and whose members account for about 80 percent of deaths each year, is considering doing just that, prompted by a recent request from the American Medical Association. Some private insurers are already covering such conversations, and many more would if Medicare did.

But some recommendations — like changing the reimbursement structure so that Medicare would pay for home health services instead of emphasizing hospital care, and so that Medicaid would provide better coverage of long-term care for the frail elderly — would require congressional action.

“We know that there may be a need for new legislation to be introduced to accomplish that, and we recognize that that’s harder to accomplish in a politically charged environment,” said Dr. Philip A. Pizzo, a former dean of the Stanford University School of Medicine and the committee’s other chairman.

The panel, which included doctors, nurses, insurers, religious leaders, lawyers and experts on aging, said Medicare and other insurers should create financial incentives for health care providers to have continuing conversations with patients on advance care planning, possibly starting as early as major teenage milestones like getting a driver’s license or going to college.

It called for a “major reorientation and restructuring of Medicare, Medicaid and other health care delivery programs” and the elimination of “perverse financial incentives” that encourage expensive hospital procedures when growing numbers of very sick and very old patients want low-tech services like home health care and pain management.

And it said that medical schools and groups that accredit and regulate health providers should greatly increase training in palliative care and set standards so that more clinicians know how to compassionately and effectively treat patients who want to be made comfortable but avoid extensive medical procedures.

The 507-page report, “Dying in America,” said its recommendations would improve the quality of care and better satisfy more patients and families. It also said the changes would produce significant savings that would help make health care more affordable.

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“If you meet their needs, treat their pain, treat their depression, get them some help in the house, your costs plummet,” said Dr. Diane E. Meier, a committee member and the director of the Center to Advance Palliative Care. Fewer patients would end up in emergency rooms getting expensive care they do not want, she said, adding, “It’s a rare example in health policy of doing well by doing good.”

The report’s linking of end-of-life choices to economic savings is likely to fuel criticism that the medical establishment and insurers will subtly pressure people to reject life-sustaining treatment in order to save money. This idea ignited intense controversy and killed a proposal for advance care planning in the Affordable Care Act when Sarah Palin and other conservatives raised the specter of government “death panels.”

One critic, Burke Balch, the director of the National Right to Life Committee’s Powell Center for Medical Ethics, said in a statement, “The report’s emphasis on cost-slashing will intensify, rather than calm, the well-founded fears of older people and those with disabilities that the renewed push for government funding and promotion of advance care planning is less about discovering and applying their own wishes than about pushing them to accept premature deaths.”

Leonard D. Schaeffer, a panel member who founded the insurance company WellPoint and is a professor at the University of Southern California, said the committee’s most “radical conclusion” was that there should be a more pronounced shift away from fee-for-service medicine, which promotes an emphasis on medical interventions in part by reimbursing doctors based on procedures rather than for talking with patients. “That’s all got to be changed,” he said at a public briefing. “And if you can’t do it with current law, guess what? You’ve got to change the law.”

Dr. Pizzo said that in surveys of doctors about their own end-of-life preferences, “a vast majority want to be at home and as free of pain as possible, and yet that’s not what doctors practice.”

Palliative care skills should be extensively taught in medical, nursing and social work schools, the panel recommended, something that Dr. Meier said would “require a revolution in health care education.” Many doctors are uncomfortable or ill equipped when it comes to broaching the subject. To ensure consistency and quality of palliative care, there should be “pretty dramatic change in all the certifying boards, accrediting boards and regulatory entities,” Dr. Pizzo said.

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The $1.5 million cost of the committee’s two years of work was financed by an anonymous donor who had no control over who served on the panel or over the report. The donor recently approved additional funding for a yearlong public education campaign.

The panel said that simply completing advance directives could have limited value because checking boxes does not accommodate the wide range of choices that an increasingly diverse American population wants. It said the system should be comprehensive, with medical wishes communicated to all of a patient’s providers and with access to palliative care and other support available around the clock.

“Patients don’t die in the manner they prefer,” Dr. Victor J. Dzau, the Institute of Medicine’s president, said at the briefing. “The time is now for our nation to develop a modernized end-of-life care system.”

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