Suicidal GOP

Now really, what are they up to with recent ambushes of seniors? AARP, Medicare, Medicaid, Social Security. As Digby says, is the GOP demonstrating suicidal tendencies?

Mitch Daniels Talks Futile Care

Indiana Governor Mitch Daniels touched the Medicare third rail yesterday when talking about how to cut the government program that covers health care for older Americans. Writes Laura Meckler at The Wall Street Journal:

He added that he understands the urge by families to push for what may be futile care. “It’s the most human thing in the world,” he said. “Your loved one is in desperate shape.” He said “we can try this thing that has almost no chance of working” but questioned whether it is worth it, especially given that “it’s going to cost an incredible amount of money.”

It's interesting that a Republican and so many others have this conversation in the framework of cost-cutting and not under the rubric of a more humane consideration regarding futile care: the harm, both physical and emotional that is exerted on family and the patient by futile care.

Daniels stopped short of suggesting, as the Obama administration did briefly, that doctors should be reimbursed for conversations with patients about end of life choices.

Expanding Hospice Care to Include Concurrent Care.

New guidelines, adopted in March, will expand Medicare and Medicaid and to cover hospice services that include "concurrent care." Both Christian Sinclair and Diane E. Meier are quoted in the article. From Amed News:

The law also calls on the Health and Human Services secretary to conduct a three-year, budget-neutral demonstration project of concurrent care for Medicare patients at 15 hospice-care sites.

The use of hospice and palliative care has grown steadily in recent years. Nearly 1.5 million patients received hospice care in 2008, up 36% from 2004, according to the National Hospice and Palliative Care Organization, which represents 80% of the country's hospices. Yet physicians offering this alternative to patients often receive hostile responses from patients and families who view it as the final step through death's door.

The median length of stay in hospice is less than three weeks.

"There are people who, when talking about hospice, they'll say, 'Don't say that word in front of my loved one,' " said Christian Sinclair, MD, associate medical director of Kansas City Hospice & Palliative Care in Missouri. "We get such a visceral reaction to changing toward a palliative care goal."

Choosing hospice care can be especially scary for patients on Medicare, said Diane E. Meier, MD, director of the nonprofit Center to Advance Palliative Care. Some private health plans cover concurrent care, but for Medicare patients -- and, until recently, children covered by Medicaid -- choosing hospice has meant giving up aggressive treatment efforts.

"The Medicare hospice benefit is the jewel in the crown of Medicare in that it's truly interdisciplinary care," said Dr. Meier, director of the Hertzberg Palliative Care Institute at New York's Mount Sinai Medical Center. "But in order to get this wonderful benefit that is hospice, you must, on the flip side, sign a form giving up the right to regular Medicare. People feel, quite rightly, that it's like signing a death certificate."

The benefit this change offers patients, families and carers at the end of life is increased time in hospice programs, greater assistance to those facing end of life planning and decision-making, and more flexibility in where they are treated.

"You go from one phase to the next phase with something to hold on to as you make that transition," Schumacher said. "Many people say, 'I wish I'd come to hospice sooner.' "

Getting patients into hospice earlier gives them access to expert advice to help decide whether curative efforts are worth pursuing further, Schumacher said. "We believe involving hospice sooner will help people forgo nonproductive treatment."

The new law also calls on Health and Human Services to conduct a pilot program to test the efficacy of the changes:

The law also calls on the Health and Human Services secretary to conduct a three-year, budget-neutral demonstration project of concurrent care for Medicare patients at 15 hospice-care sites.

The demonstration project will test whether paying for concurrent care helps patients and saves Medicare money. Then the HHS secretary will recommend to Congress whether to change the hospice-care payment policy. A Centers for Medicare & Medicaid Services innovation center created in the health reform law also may be able to act on the recommendations. Hospice care cost Medicare $11.2 billion in 2008, according to the Medicare Payment Advisory Commission.

Some of the greatest benefactors of this change may be ill children:

In the meantime, children with terminal illnesses and their families should benefit from Medicaid's coverage of concurrent care efforts, Dr. Sinclair said.

"In pediatrics, the prognosis for patients can be a lot harder to define," he said. "Having a concurrent care model is helpful, because those families need a lot of help, especially from psychosocial and the other resources that hospice can provide."

Decline in Hospice Stays and Duration?

Howard Gleckman of the Urban Institute writes at Seattle's Local Health blog that hospices are seeing fewer patients and shorter stays and suspects it caused by doctors who don't refer patients early enough and misconceptions about hospice care:

Suddenly, many hospices are admitting fewer patients. Others are increasingly caring for people for just days or hours before they die. The result: cash-strapped hospices are cutting back on nurses and aides, and patients are missing out on critical end-of-life care.

It is not clear why it’s happening, but some hospice officials blame both a bad economy and Medicare rules that unintentionally discourage doctors from referring all but those who are about to die.

Even though hospices have been operating in the U.S. for three decades, they remain widely misunderstood. Hospices provide medical care, pain management, spiritual and social care and volunteer support for those nearing the end of their lives. And their patients often live longer than if they were still receiving full-blown medical treatment.

Nearly all hospice care is paid by Medicare, but unlike most providers, hospices are paid a fixed daily rate (on average about $140-a-day for home care patients). If a hospice provides care for less, it keeps the difference. If a patient requires very costly care, the hospice can lose money.

The number of patients served by hospices increased from about 1 million in 2004 to nearly 1.5 million in 2008, while the number of hospices grew from 3,600 to almost 5,000. Most of this explosive growth has been driven by for-profit companies.

But in recent months, hospice officials have seen a downturn. In some states, such as Oklahoma, heavy competition has forced consolidation, and at least 10 hospices have closed in the past year.

Elsewhere, hospice officials blame the bad economy. Patients who have lost jobs–and insurance—may be waiting longer to visit the doctor and consequently are diagnosed with terminal illnesses at a very late stage.

Some hospice executives say the poor economy may also be driving doctors to hold on to patients longer.

Here’s why: Once a patient joins hospice, she’s likely to see her physician far less often. Her doctor can usually order tests and treatments only to keep her comfortable, and not to try to cure her terminal disease.

And while it may still be appropriate for, say, cancer patients to receive costly drugs or even radiation therapy to relieve pain, hospices must pay for these treatments out of their daily Medicare rate.

That inevitably can create tension between the hospice and the physician.

And it may add up to less money for doctors at a time when they are already feeling squeezed. One physician I spoke to strongly rejected this argument, insisting that declining compensation does not slow referrals.

But another—an oncologist who frequently refers to hospice—acknowledged the problem. “There is a financial deterrent,” she says.

At the same time, new Medicare rules may be further discouraging physician referrals. Medicare has begun cracking down on a handful of hospices that are making big profits by taking on chronically ill, but not terminally ill, patients.

While hospice patients are normally expected to have six months or less to live, some hospices have many on their rolls for a year or more.

In one attempt to stop this practice, Medicare now requires doctors to write a brief narrative describing why a patient is appropriate for hospice. Trouble is, says one hospice official, “We’re getting a lot of pushback” from doctors.

In 2008, more than one-third of patients were enrolled in hospice for a week or less, and some organizations are seeing the number of short stays increase, perhaps because these requirements may be making already reluctant doctors even less willing to refer to hospice until their patients are actively dying.

Mark Murray, president of the Center for Hospice and Palliative Care in South Bend, Ind., says that in the past year, eight percent of his referrals died before they could even be admitted, and 20 percent died within 48 hours.

Those last-minute decisions put enormous financial pressure on hospices and make it impossible for patients to get the full benefit of end-of-life care.

These disincentives come on top of a long-standing reluctance on the part of many doctors to even talk about hospice. In a 2009 study, more than half of patients with stage IV lung cancer said their physicians never even raised the option.

I am a huge fan of hospice: My wife is a hospice chaplain and both my father and father-in-law were hospice patients. These organizations are a model for coordinated care that other health care providers would do well to copy.

But doctors need to be persuaded to use hospice. And that may mean changing a payment system that may be discouraging them from using this valuable service.

Who's Rationing Now, Mayo Clinic?

That and other alarming positioning in the "pro-corporate profits" publication. Like the fact that health care is not a right, implied by support for the Mayo clinic's decision to drop Medicare at one of its facilities. Come on, there's more money to be made from treating the wealthy. Let's continue to ration by class! You can't always assume one's position by their use of terms - the left is as angry these days about the lack of reform in the health care bill as the right - but the WSJ using the derogatory "ObamaCare" in a piece of reporting?

It looks to me as though this may not be a bad development if played right by the administration - not saying I think they're capable of taking any political advantage from opportunities handed to them on a platter.

The medical industry's attempts to undermine the benefits of Medicare won't be popular with the more than 44 million who get their health care through the program, including the 850,000 in Arizona who will not have to switch hospitals and travel greater distances for necessary care. I'm hoping Mayo's denial of Medicare patients will cause increased support for the program - and greater advocacy for more like it, programs that tackle the profit-driven delivery of health care in this country.

There's more money to be made from private plans, claims Mayo. Here's a clip:

Mayo is probably a leading indicator of where other hospitals and doctors are headed. Physicians on average earn 20% to 30% less from Medicare than they do from private patients, and many are dropping out of the program. While about 92% of family physicians participate in Medicare, only about 73% of those are now accepting new patients. In some specialties—neurology, oncology, gynecology—in places like Manhattan and Washington, patients can struggle to find any doctor who'll accept Medicare.

The $500 billion in Medicare cuts planned as part of ObamaCare won't help this trend. The hospital industry agreed earlier this year to chip in $100 billion over the next decade in lower annual payment increases for Medicare. The chief Medicare actuary estimates that up to 20% of hospitals could become unprofitable as a result of the scheme.

The irony is that the Obama Administration has repeatedly praised Mayo as an example of the efficiency and lower cost that will spread everywhere if ObamaCare passes. And it's true that Mayo is a sterling example of the kind of health reform that many economists—notably White House budget chief Peter Orszag—extol.

Not a Dime of My Tax Dollars for That Brand Name Drug!

Dr. Scott Gottlieb has rallied the "America has the best health care in the world" crowd with his pro-doctor, pro-medical industry op-ed in today's WSJ.

Let me just say up front that it's hard to find something good in this health care bill already without making up poorly-framed arguments that those poor doctors and suffering medical corporations are going to have to, you know, adjust their practices. Had the industry better regulated itself over the past few decades, we wouldn't be where we are now. In a predicament where health care coverage is tapping the country's economy and still not reaching the majority of citizens effectively.

Of course the Wall Street Journal has a particular clientele, one that belongs to a class of society pampered by employer-paid stellar health care coverage. To claim that our system is currently working is to ignore the 45,000 deaths a year from inadequate health care access, or the 50 million Americans who have no health care at the moment. But this demographic never saw health care as a right, only as a commodity. If those poor bastards in a Texas had studies harder, pulled themselves up by their boot straps, they'd have decent jobs and decent health care coverage. In other words, not having health care is shameful and indicative of laziness. So goes the privileged reasoning.

Gottlieb makes the following claims in his piece:

While the AMA supports health care reform (and it's a dogged piece of legislation that has little to do with reform and all to do with appeasing the medical industry), various surgeon and specialty associations oppose it. That's because they will be hard pressed to pursue their specialties with the same abandon if they hope to accept Medicare payments. The legislation reigns in specialists - a group that has ballooned over the past few decades simply because the AMA has encouraged licensing of such specialists and because that's where the money is.

He protests the new powers given to Medicare and Medicaid to select cheaper services for patients, refusing to pay for name-brand drugs and treatments when generic will do. Of course the medical industry is up in arms over this. The overhead on name-brand services is what has made the industry such a rich and powerful loggerhead in medicine. Basic economics shows that Medicare and Medicaid can't afford - and shouldn't pay for - such overpriced services when cheaper ones are available.

Gottlieb argues that those who want to sue Medicare for not covering less expensive services will be discouraged from suing for them. To this I say: If you want a specialty services, pay for it. As women are being forced to do with the "specialty" service of abortion. For women the law of no coverage is simply religious discrimination but once mention that making economic decisions regarding other coverage is unfair and you get a gaggle of "free-market" conservatives claiming that Medicare has too much power. Let the patient pay for their extraordinary care if they think it will better help them. This isn't rationing. This is practicality in buying as far as I am concerned.

Gottlieb also criticizes what he calls incentives for independent specialists to merge or consolidate with other practitioners in order to keep costs down in delivery. This too is a practical concern. Independent specialists cost more, their overhead is not shared with other practitioners and therefor must come from somewhere. Until now that has been from Medicare and Medicaid or high-end insurance companies willing to pay more when the employer or patient pays more. If we want to cover all citizens and apply government regulation to government plans to reign in costs, we have to address the excesses. But if I were an independent specialist, I would be squealing too. My fat run is coming to an end.

Most of the cost-saving programs Gottlieb is criticizing are really demonstration programs, trials by Medicare to see what works. Instead of addressing the excessive costs of health care today, he is focusing on the wrong audience, the doctors, privileging their position - as all associations are of course apt to do - above that of the patient. But that's because Gottlieb is opposed to treating medicine as a right, affordable and accessible. Instead he wishes it to remain a commodity that has led to overspending.

He writes:

Regulation of medicine has always been a local endeavor, and it's mostly the province of medical journals and professional medical societies to set clinical standards. This is for good reason. Medical practice evolves more quickly than even the underlying technologies that doctors use. This is especially true in surgery, where advances flow from experimentation by good doctors to try different surgical approaches.

Sorry, but industry self-regulation is not regulation. As the medical industry has proven over the past decades, the great percentage of killers in the US have gone unaddressed by the big money innovators. Equipment and drug manufacturers have both pressured the public into pursuing boutique illnesses while heart disease and cancers have proven to go unchecked. That advancing innovation comes from small-time, independent surgeons is a fallacy. Innovation now, as Gottlieb calls it, is large corporations finding niches that will make them quick money.

The rallying cry worked for abortion has been "Not my tax dollars!"; how about using it to curtail excessive drug company profits and "innovations" in medicine that only address boutique treatments? When we start seeing advancements that change lives for those suffering the primary killers, preventative medicine that reduces costs and increase quality of life, and more affordable prices for all Americans, we can then discuss the excessive ways of the medical industry as innovative.

Gottlieb, a fellow at the notoriously conservative Free Enterprise Institute is approaching medicine from the medical industry's position. We've unsuccessfully tried that for decades. It's time we approach medicine from the standpoint of the patient.

Medicare Strike Force Taking It Back.

One of the greatest holes we throw our money into is Medicare - and not because we don't have a population of elders in need and not because we don't have a great program that can serve them, but because it is so very easy for hospitals and other medical entities to take advantage of elders when so little oversight has been built into an excessive medical industry.

It's great to see money that should be used for our elders being brought back to the system from preying felons! I'm just waiting for some dimwit to scream, "rationing!"

Thirty people have been charged in three cities for their alleged roles in schemes to submit more than $61 million in false Medicare claims as part of the continuing operation of the Medicare Fraud Strike Force, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius and Assistant Attorney General Lanny A. Breuer of the Criminal Division announced today. Also today, the Departments of Justice (DOJ) and HHS announced the expansion of Strike Force operations to Brooklyn, Tampa and Baton Rouge in the fifth, sixth and seventh phases of a targeted criminal, civil and administrative effort against individuals and health care companies that fraudulently bill the Medicare program.

Five indictments were unsealed today in Miami, Detroit and Brooklyn, following the arrests of 25 individuals in Miami, four individuals in Detroit and one in Brooklyn. In addition, Strike Force agents executed four search warrants at businesses and homes in Coconut Creek, Fla.; Miami and Brooklyn.

The joint DOJ-HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. Strike Force teams are operating in seven cities in the United States: Miami, Los Angeles, Detroit, Houston, Brooklyn, Tampa and Baton Rouge.

“When President Obama took office, he promised a new commitment to cracking down on the criminals who steal billions of dollars from Medicare each year through fraudulent claims,” said HHS Secretary Kathleen Sebelius. “Today, HHS and DOJ are following through on that commitment with the announcement of three new Medicare Fraud Strike Force teams in Baton Rouge, Tampa, and in Brooklyn. Along with teams already operating in Miami, Los Angeles, Houston and Detroit, these Strike Force operations will allow us to concentrate our agents and resources on the criminal hubs where we know a significant share of fraud occurs. Medicare is a sacred promise to America’s seniors and we will do everything we can to protect it. The announcement we’re making today is a significant step towards securing Medicare for seniors today and generations to come.”

Getting Lost in the Hypocrisy.

The American Catholic writes that the Republicans are guilty of hypocrisy by now, in the debate to reform health care, standing against cuts to Medicare.

Despite the collective amnesia of the American people, to the obvious joy of Republican political strategists, historical record on the other hand points out a glaring contradiction that makes their arguments seem wholly and entirely politically pragmatic. For example, during a vote in the House on April 2, 2009 the majority of House Republicans sought to end Medicare as it currently exists in the vote on the Republican budget alternativesubmitted by Budget Committee Ranking Member Paul Ryan (R-WI). The amendment won support from nearly four-fifths of House Republicans and effectively would have converted Medicare into a voucher system providing future retirees with a fixed amount of money to buy private insurance plans.

Valid point, sort of. But what the writer gets wrong is 1.) the nature of the cuts to Medicare as proposed by Democrats; and 2.) the "inevitable" rationing that faces the country under health care reform and such budgetary cuts.

I can't blame the writer, really. Democrats have avoided the rationing conversation since the beginning when they should have embraced the discussion to reveal the ways in which current practices of rationing will be regulated by government intervention. And they haven't clearly defined how they will cut Medicare, allowing the cuts be wrongly characterized as simple rationing instead of cutting the over-treatment, over-medication, and over-testing that is done to seniors - with little benefit - under the current system.

Hypocrisy is one thing that unfortunately both sides of the aisle have engaged in for their ends. Clearer information is needed to debunk the rationing and cuts accusations. I wish the media were working harder to set The American Catholic and other misinformed parties straight.

McCaughey and Weiner Scrap on Morning Meeting.

Don't miss this video boxing between it's-gonna-kill-the-elderly Betsey McCaughey and New York Senator Anthony Weiner about health care reform:

via dailykos. And you can find Ben Smith's coverage at politico.