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Sunday, January 9, 2011

Let’s drop demagoguery on ‘death panels’

By MORTON KONDRACKE

Another Viewpoint

It looks as though “death panel” demagoguery has won again. I’d like to think the victory is temporary and that Congress can debate health costs and end-of-life care rationally.

Fear-mongering from former Alaska Gov. Sarah Palin, right-to-lifers and talk-show rabble-rousers kept a perfectly reasonable provision out of Congress’ new health care law that would have encouraged physicians to talk with seniors about end-of-life choices.

They also attacked provisions to study the comparative effectiveness of drugs and medical procedures, plus an Independent Medicare Advisory Council to enforce savings, as forerunners of government “rationing.”

Palin declared on her Facebook page during the 2009 health care debate that “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 bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society’ whether they are worthy of health care.”

The “death panels” issue roared back last month with a decision – laudable in its merits, if dubious procedurally – by the Obama administration’s Medicare chief, Donald Berwick, to authorize government payment to doctors to hold voluntary discussions with patients about their care at the end of life. Now Berwick has been forced to drop the proposal.

“Death panel” talk also was fueled by the Food and Drug Administration’s decision to ban the expensive drug Avastin for use by gravely ill breast cancer patients.

In an opinion piece in the Wall Street Journal headlined “‘Death Panels’ Come Back to Life,” attorneys David B. Rivkin Jr. and Elizabeth Price Foley argued that “the Avastin story is emblematic of the government’s broader agenda to ration care based on cost and politics. … When government sees insufficient benefit, all but the wealthiest and most politically connected will have to go without” life-saving treatment.

Really, there are two issues here – end-of-life counseling and “rationing” – that ought to be debated separately. Both have big cost implications, but counseling also can be part of a cultural change, already under way, that leads terminally ill people and their families to choose a humane “good death,” avoiding painful (and expensive) heroic measures to keep patients alive.

Voluntary counseling sessions as part of a Medicare beneficiary’s annual physical could lead a senior, healthy or ill, to equip himself or herself with an advanced medical directive (“living will”) and complete a durable power of attorney appointing a surrogate to make medical decisions in case of incapacity.

A recent study in the New England Journal of Medicine found that nearly 70 percent of older adults have living wills detailing their end-of-life wishes.

The use of hospice care at the end of life – where patient comfort and access to family is emphasized over merely keeping the patient’s heart beating – also has increased significantly.

There are significant savings to be had by opting to spend one’s last days in a hospice as opposed to an inten-sive care unit – perhaps $50 billion a year nationally – but the opportunity to choose is what’s even more important.

To liken a voluntary consultation to a “death panel” is pure demagoguery.

The issue of rationing is not so cut-and-dried. America already rations health care by income, by access to health insurance and regular medical visits. Studies by the Institute of Medicine and the American Journal of Public Health indicate that lack of health insurance leads to 18,000 to 45,000 deaths each year.

One good way to cut America’s soaring health care costs is through research in health care delivery. As the Dartmouth Institute for Health Policy and Clinical Practice has shown, Medicare alone could have saved $50 billion from 2001 to 2005 if all hospitals across the United States were as efficient as the Mayo Clinic.

Meantime, it would be far more effective to create a health care system in which patients were cost-conscious consumers, as opposed to having government agencies decree who will get what kind of care.

Theoretically, to save money under President Barack Obama’s health plan, an agency such as the independent body created under the law will make those decisions – but they will be reversible by Congress.

Obamacare won’t be repealed by Congress, as Republicans vow to try, but it can be improved. With any luck, the debate on how to do it will be conducted rationally. But maybe not.

Morton Kondracke is executive editor of Roll Call, the newspaper of Capitol Hill.