Politics

A Physician's Take on the "Death Panel" Revelation

The truth about end-of-life counseling

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Over the Christmas holiday weekend, The New York Times revealed that the Obama administration's Medicare regulators have enacted new regulatory guidelines, in complete defiance of Congress, that will result in health care providers receiving payment to give annual "end-of-life counseling" to their patients.

As a physician, I can tell you that we doctors do routinely have end-of-life discussions with our patients. This is a necessary part of our job. But we do it when it is appropriate and indicated by the clinical situation. And we have never expected payment for this. It is part and parcel of the practice of medicine.

Medicare, however, will now incentivize health care providers to have this discussion annually, as part of an annual physical exam. Providers will get paid extra if they have this conversation. But consider the implications: When discussing such matters with an otherwise healthy and possibly youngish senior, the "directives" that health care providers will elicit may be significantly different from what they would have been if the patient was actually confronting a life and death situation. One's directives are often quite different when talking about a theoretical future versus a real situation occurring in the present. After all, the future might offer technological advances that are not available at the time of the theoretical discussion, thus making a patient reach a very different decision when that future reality arrives.

Furthermore, as typical of all Medicare regulations, there are certain requirements that must be fulfilled in terms of both the discussion and the patient directives in order for the end-of-life counseling to qualify for physician payment. And therein lies the rub. The whole idea is to get younger, healthier Medicare patients to give advanced directives that will be used at a later time to deny them care. Remember that ObamaCare cuts Medicare by $500 billion—and that doesn't even take into account the coming demographic cataclysm that awaits the program when the baby-boomers become Medicare beneficiaries.

That's why the new policy has been dubbed a "death panel" by its opponents. One can easily see the ulterior motive behind the decision to incentivize health care providers to have annual, Medicare-designed end-of-life discussions with their patients. It's to allow for denial of care at a time when Medicare money is scarce.

Indeed, this is precisely why Congress removed the end-of-life counseling provision from the final health care bill. When the public learned of this provision, there was an outcry against it.

But now the executive branch has circumvented Congress, ignoring both the legislative text and the intent of the legislature, by enacting the very provision that Congress decided to remove. And it has done so using the regulation-writing process.

This last point should disturb anyone concerned about the integrity of our democratic republic, regardless of where one stands on the matter of health care reform or end-of-life discussions. The executive branch is enacting by regulatory fiat what the legislative branch explicitly opted not to enact. This can only lead to the tyranny of an unelected bureaucracy.

Dr. Jeffrey A. Singer is a general surgeon in private practice in the metro-Phoenix area since 1981, and is Treasurer of the U.S. Health Freedom Coalition.

Editor's Note: In an unexpected reversal, the Obama administration has announced that it will not implement the end-of-life planning regulations discussed in this article.

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  1. Libertarians should support healthcare reform, since they’ll get free pills for their small dicks.

    Read my blog.

    1. Well! After that brilliant comment I can’t wait to rush over to your probably equally genius infused blog! Ow! Sprained my sarcasm muscle. Seriously, Mr. Rather. Upset at being fired from CBS after all this time?

      I still can’t get over the silly picture of alleged doctors wearing their white coats in the Oval Office. Were they even real doctors or stock photo models? Was that really Obama or an animatronic double?

      1. QD, are you completely male*?
        Heller posts all the stupid comments. I feel sorry for him because his head was damaged in his test tube conception.

        *the new retarded

        1. Heller posts all the stupid comments.

          Come now, rectal. I think you are doing yourself a great injustice by saying Heller posts all of the stupid comments. Easily 2/3 of what you post is stupid, and the other third is barely readable at best. Don’t be so hard on yourself.

        2. Rectal you’re fucking retarded. I’ve spoofed you maybe 10-15 times. Did it ever occur to you that many other here don’t like you and have been using my spoof website to mock you? Guess not, dumbfuck.

        3. Men are retarded and have small dicks. Why else would they reject my sexual advances?

          Read my blog.

  2. Lab coats all around!

  3. I realized it’s getting really bad when my reaction any more is “Oh! Shocker! Who could have seen this coming?? Hahahahahahaha! Those fuckers! I gotta get back to work…”

    Fuck….I don’t Love Big Brother?, but I am getting too worn down to argue about/with Him? anymore…

    *shuffle off to reflect on being worn down*

  4. Big fan of death panels, personally. Looking forward to hearing “Run, runner, run!” from time to time.

    1. Ha! I’d rather go to Carousel. RENEW! RENEW! Pfffft! Kaboom! I guess it beats dying of cancer…

  5. The whole idea is to get younger, healthier Medicare patients to give advanced directives that will be used at a later time to deny/b> them care.

    Nope. That’s a serious distortion.

    1. Explain it then.

    2. Neu Mejican = previewitard

  6. oops.

  7. the death panels are going to come in handy for resolving the government worker pension shortfalls.

  8. I don’t know why we even have a Congress when Executive Departments can issue Regulation with the power of Law.

    I propose we scrap both the Congress and Judiciary entirely, and just let the President rule by Regulatory dictat.

  9. This is why we need the REINS act, and why it should be a bipartisan effort. Regulatory agencies are starting to do end-runs around both Congress and the judiciary now, pretty much by just ignoring them. That has to stop.

    1. They are not doing end-runs around Congress. Congress gives them that authority to make such decisions.

      1. Congress gives them an “intelligible principle” (basically meaningless) and then agencies run with that and do whatever they want. Designating what we breath as a pollutant, for example.

        1. Breathe out*

        2. They give them authority. That’s all they need.

  10. You see, I actually think this was one provision I could live with (If you pardon the irony).

    If these people are using tax dollars to keep them alive, I’d like the fact that someone is telling them, “have you considered ending it earlier?” In fact, I think that’s about the only provision of the bill that would have been responsible – no wonder they threw it out.

    1. I have no problem with this either. If we are going to spend tax dollars on health care is it so outrageous to try to get the best value for our bucks? I know it sounds callous to talk about people’s lives like that but lets get real. The money is limited and health care is not free and despite what my bleeding heart liberal frieds (God bless ’em)say you most definitely can put a price on someone’s life.

    2. I have to mostly agree. As long as people are still free to say “do everything you can to keep me alive as long as possible”, this is one of the least troubling provisions of the healthcare monstrosity. “Death Panel” is not an apt description for what is being discussed here and is deliberately misleading.

    3. The ultimate effect of this will be to promote an ethos that makes the elderly feel guilty and ashamed about wanting to continue to live. The effect will extend beyond those relying on Medicare, eventually permeating all of society. Seriously, this is hideous.

  11. “In an unexpected reversal, the Obama administration has announced that it will not implement the end-of-life planning regulations” That is until they can figure out how to implement it without our knowing about it or on the next Christmas eve.

  12. You can’t kill death panels.

    1. yeah, there is a way. I saw it on the Walking Dead and in all the Romero films: Go for the head!
      Oh fuck, it’s the govt: The head is missing.

      1. It’s not missing, it’s just up the ass.

        1. Great! I am an “ass man” so I can bang it and get a blow job at the same time!

  13. The executive branch is enacting by regulatory fiat what the legislative branch explicitly opted not to enact. This can only lead to the tyranny of an unelected bureaucracy.

    In case you haven’t noticed, CO2 is now, almost magically, a pollutant covered under the clean air act.

    How long were you living in that cave, Doctor?

  14. The executive branch is enacting by regulatory fiat what the legislative branch explicitly opted not to enact. This can only lead to the tyranny of an unelected bureaucracy.

    “Lead to”… ha-ha, that’s funny.

    We’ve ignored constitutional limits on government authority for nearly 80 years now, and executive branch rule by regulatory fiat is at least 50 years old.

    “Lead to” bureaucratic tyranny…. funny…

  15. It’s to allow for denial of care at a time when Medicare money is scarce.

    Repeating the distortion doesn’t make it more true.

    1. “”It’s to allow for denial of care at a time when Medicare money is scarce.””

      I will be laughing my ass off when a republican president takes over and uses that authority to trim the budget.

    2. Repeating the distortion doesn’t make it more true.

      NM, do you even concede that they will have to do something? Is there really any possible way to provide the benefits claimed with available or even future money? Is there some way the government will be able to produce and unlimited supply of something for which there is a limited supply? Magic?

      1.Guarantee benefits
      2.?????
      3.Benefits for everyone?!

      1. The government should start stealing underpants. You know, for profit.

  16. “”After all, the future might offer technological advances that are not available at the time of the theoretical discussion, thus making a patient reach a very different decision when that future reality arrives.””

    I don’t see that as much of a problem if they are renewing it every year.

    Someone could always add to their advance directive, “keep alive by all means necessary.”

    “”I don’t know why we even have a Congress when Executive Departments can issue Regulation with the power of Law.””

    I’ve always thought of executive orders as an order to those whom the executive has direct control, which would not be the citzenry. It’s like the CEO of company X directing its employees. It may trickle down a bit much like the CEO of Walmart decisions affect its customers. But it’s not like creating law.

    Of course this wouldn’t be much of a problem if Congress wouldn’t give the executive more authority by moving things into executive departments, be it health care, or war.

    Congress gave Bush wide authority with terrorism, for Obama it’s health care. But the next President can change how he/she sees fit by executive order. That’s one of the points I try to enlighten my liberal friends about the health care law. Even if one likes universal health care, the law was bad because it moves care much deeper into the realm of partisan politics.

  17. “The executive branch is enacting by regulatory fiat what the legislative branch explicitly opted not to enact.”

    And unfortunately much of our citizenry sees no issue with this, particularly my own generation (I was born in 1987). I’ve had arguments with brick walls my coworkers in which it was obvious that they did not understand the separation of powers prescribed by the Constitution (also, apparently Bush never did anything and it’s better for Obama to do the wrong things than to do nothing).

    1. “””The executive branch is enacting by regulatory fiat what the legislative branch explicitly opted not to enact.”””

      It’s by design. The legislative branch explicitly gave the authority to the department which the executive has control.

      If the Rs hold 2/3s of government again, they will use it to their advantage. If they changed the law to move that authority back to Congress, I’d be impressed.

      1. I realize the horse is out of the barn, but technically the authority to legislate was explicitly entrusted to Congress by The People and Congress does not have the legitimate authority to transfer legislative authority to a bureaucracy.

  18. Just two days ago, a couple of my friends were making of those Tea Party people and their silly death panel lies.

    1. Argh, making FUN of those Tea Party people.

  19. The regulatory creep and the massive increases in government spending are two heads of the same hydra, both withe the agenda of bigger, more omnipotent (but increasingly impotent) federal control.

    Put the brakes on spending, and it puts the muzzle on the bureaucrats -BUT- the more regulations the bureaucrats manage to make up, the louder they and their enablers can whine that funding is needed. A two pronged approach is called for – one, to slash the budgetary items resulting from various executive agencies simply creating work for themselves by regulatory outreach, and second, Congressional oversight and revue of the ‘make shit up as we go along, just because we can’ attitude and culture flourishing in the executive branch. Such crap needs to be cut off at the knees, figuratively, such that if they can’t color inside the lines on their own, then they get no more money to buy fucking crayons. Political partisans who have used regulatory ‘authority’ to end run agenda topics that have been unaddressed by Congress should be first in line for a severe dressing down – with Lisa Jackson of EPA and Alex whateverthefuckhisnameis at the FCC being headliners for the bloodbath, for starters.

  20. Medicare regulators have enacted new regulatory guidelines … to give annual “end-of-life counseling” to their patients.

    How long until *all* patients, especially pediatric, have such counseling?

  21. I don’t know, I’m actually in favor of rationing. I mean, if you are going to receive subsidized care, shouldn’t there be some sort of cut off limit? IF you’re paying for your own care, go nuts, but if I’m paying for it, I want a say in how much you receive.

    1. Hear! Hear! When you take the food from my family’s mouth, I get to tell you how much you can take.

    2. that would be fine but the regulation requires all insurers to follow suit so there is in essence no longer a choice between plans just a choice between providers. The insurers will be acting only as a utility much like the gas or electric utility companies. You will no longer have the choice of paying for unlimited insurance provided by private insurers.

  22. MNG is right. Advance directives don’t “deny” anyone care. They are an expression of the patient’s consent (or refusal to consent) to care, used only when the patient is unable to communicate their desires.

    The advanced directive bit wasn’t the death panels, anyway. The death panels are the federal boards that will be establishing the standard of care to be provided to patients, based on the cost of the procedure balanced against the patient’s expected future contributions to society.

    1. Correct and in the house version there were to be 27 members on the panel and only one had to be a physician. i don’t know what the final panel make up was to be I wasn’t about to read another 2K + pages

    2. Thank you. I thought that that was what “death panel” was supposed to mean. “Death panel” makes no sense when applied to discussions of advanced directives. People who are calling this “Death panel” are making themselves sound stupid. Assuming that government is going to be heavily involved in healthcare (which I am opposed to, but seems likely nonetheless) this seems like a pretty sensible regulation (not that that makes it OK in principle).

      1. I like you. You get a new hip when the time comes.

        1. uhh.. hip…hip.. back ordered again..

          How bout we just dont collect that liver of your wife’s today instead?

          Will giva call if we gets some, er… Salvage, thats it, in before next month..

  23. http://www.washingtonpost.com/…..in-twitter

    This thread has been overtaken by events. Obama is apparently backing down on this one.

    1. This thread has been overtaken by events. The events are being spun. Obama is apparently backing down pretending to back down on this one.

  24. First, it’s a bit disingenuous for Singer to claim doctors now don’t get paid for these discussions; they do, the discussions happen during an appointment, and they are paid for as much as advice to lose weight, etc.
    Aside from that, the problem lies in what happens when an agent of the government (which is what doctors become in this case) “suggest” something or other.
    It’s not a matter of ‘whether’, it’s a matter of ‘when’ such suggestions become the sort of suggestions you get from the IRS about how much money you owe.

  25. Your hair stylist is the person who can really tell you as to what would be best for your hair.
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  26. Medicare, however, will now incentivize health care providers to have this discussion annually, as part of an annual physical exam. Providers will get paid extra if they have this conversation.

    Can I tell my grandma each year to consider killing herself and get paid, or do I have to be a doctor to get into the racket?

    1. Old Mexican: Please let me see your papers…the ones showing you are qualified to tell people to “Fuck Off and Die!” Otherwise, please continue telling people to just “Fuck Off!”*

      * You eminently qualified to do this

  27. I see the concern about the executive fiat, but there are bigger problems to worry about than people signing advance directives early.

  28. “Editor’s Note: In an unexpected reversal, the Obama administration has announced that it will not implement the end-of-life planning regulations discussed in this article.”

    Yeah, until everyone forgets about it for a while.

    Entitlements for old people are an existential threat to the government, it’s clear to everyone that voting demographics prevent a democratic solution, so the technocracy has taken it upon itself to implement a f… an ultimate solution to the problem of the elderly. This is step one, step two is the bolder nudge, and step three is compulsion for all the people who failed to respond to the nudge, just like every other progressive initiative.

    Some ideas (this, HCR in general, Net Neutrality, carbon control, war with Iran) just have too much monomaniacal drive behind them and not enough opposition in front — at least not until they’ve managed to do some major damage. It will happen eventually, just give it time.

  29. As an oncologist who actually works with people to make end of life decisions and as someone who has had family members who needed end of life counseling, this is a total bunch of crap. No decision is irreversible and noone is going to ask a healthy person to declare themselves a DNR. Counseling about end of life decisions takes time – at least an hour or more – how this this be done unless you can bill for it – for most of us without scams, all we bill for is our time. When it is you or your parent who needs a discussion regarding complex decisions, hospice care, etc and your doc gives you 5 minutes in a busy office writing on his computer and fielding phone calls, I doubt you will feel this was a positive interaction. Death panels are what the Arizona governor recently did denying proven lifesaving care to young people who needed transplants and failure to provide care to the uninsured.

    1. You may be right that there’s the potential here for a hemorrhaging of tax money while medicare wastes man-hours about advanced directives.

      But you aren’t saying that human beings shouldn’t consider a living will. (I.e., you deal with cancer patients and you’re not saying that a “death panel” is a bad idea–only that it costs money and doing it every year is a waste of it.)

      Regardless, it’s still not a a “Death Panel.” That’s just needless red team hyperbole and I would never trust any doctor who chooses to use such a derisive propagandist term for an incredibly important and overlooked concept. The same as I wouldn’t trust a climate scientist who says “big oil.” It’s the same principle. How can your opinion be medically/scientifically sound and unbiased when your speech isn’t?
      [Not referring to you here, rather Jeffrey A. Singer.]

    2. And why do we need to be paying you $600 dollars an hour to have this talk, year after year?

      You don’t think anyone else but a doctor could productively give this talk?

      How about we have counselors at senior centers give these talks instead, for $30 dollars an hour?

  30. There’s no death panel. Stop reading goddamn red team chain emails and treating them as news. [Ditto for blue team, but this isn’t one of theirs.]

    They’ve already been doing this for years at my U.S. government socialized-medicine healthcare provider (aka the VA). They periodically ask you:
    “Do you know what a living will or advanced directive is?” Y/N
    “Do you have one?” Y/N
    “Do you want more information about it?” Y/N
    If Y, you get a pamphlet in the mail explaining how to set up a living will.
    If N, nothing happens.

    There is absolutely no other follow-up, nor do they make recommendations about when/where/why/how/whether you should kill yourself. [And they don’t ask if your loved ones have given you the authority. They only ask about YOU, since you only control YOU.]

    Calling these questions a death panel would be like calling the old airlines “Have you been with your luggage the whole time?” questions a terrorist panel. Yes, they are questions related to death/terrorism, but nobody is trying to kill you or make you a better terrorist.

    Even if fully implemented (which it already is for veterans) IT’S NOT A FUCKING “DEATH PANEL.”

    What they are asking you is a subset of the absolute core concept of libertarianism, which is that you own yourself–even when you’re unconscious. If you don’t have a living will, then the government may decide that it owns you*. See Terri Shiavo and Nancy Cruzan.

    Asking you if you’ve thought about whether you want the government to own your body and decide by default whether you live and die or whether you’d prefer to retain those rights yourself is pretty fucking subversive libertarianism for a socialist administration and congress.

    We should be cheering for the so-called “death panel.” I mean, holy shit, are we libertarians here or not?

    Yes, you smart-asses can drink to that if you want: I agree booze eases the pain when Fox News bullshit spills over into the rational world most of us liberty-minded people try to live in.

    P.S. They also ask you if you want to be an organ donor. If you say “no” nothing happens. They don’t guilt-trip you. Obama doesn’t come and cut you open on the spot and give your kidneys away.

    * Moreso than it already does.

    1. It’s a death panel damn it!!!

    2. “P.S. They also ask you if you want to be an organ donor. If you say “no” nothing happens. They don’t guilt-trip you.”

      See my comments on the reality of my 80 year old mother, slowing losing her faculties bit by bit, knowing it, and being badgered by doctors, salesmen, and company representatives in directions she doesn’t want to go. She feels pressured all the time.

      It’s like social services, that keep on asking children if their fathers touch them in the naughty place, and won’t stop until they get the answer they want.

      Or another time, a gal I know was in an accident. She was turning left across a lane that was a highway exit. Someone coming off the exit and hits her. She bangs her head against the window.

      A cop comes and starts asking questions.

      What happened?
      The left turn light came on, I turned, but the other car didn’t stop and hit me.
      The left turn light was on?
      Yes.
      Are you sure?
      Yes.
      And you couldn’t be wrong?
      Well, maybe. I guess so….

      Nice. Badgering a frightened young woman with head trauma until she gives you an answer that makes the paperwork all tidy.

  31. I would like to reinforce what jws and Jcalton have said on this. These discussions do take time, and time is all many physicians bill for. Cutting this reimbursement to physicians will result in fewer people actually having this discussion with their doctors.

    Currently, our ability to prolong the functioning of a gravely damaged human body greatly exceeds our ability to repair and restore functioning to gravely damaged human bodies. Most end of life treatments are merely prolonging the inevitable end result of trauma and disease. Delaying death is not the same as healing.

    People ought to have access to conversations about what end of life treatment means, before they are incapacitated and unable to make their wishes known. This should be evident to anyone with a libertarian mindset.

    1. “These discussions do take time, and time is all many physicians bill for.”

      And why does this discussion have to be with someone who charges $600 dollars an hour? And why should this discussion should be foisted on a patient who hadn’t requested it?

      Look. Cover the talk for any patient who makes an appointment to have the talk, and find someone less expensive to pay for having the talk. There is nothing to diagnose, treat, or prescribe involved – a doctor is not necessary.

    2. “People ought to have access to conversations about what end of life treatment means, before they are incapacitated and unable to make their wishes known. This should be evident to anyone with a libertarian mindset.”

      Libertarians understand that people should not be treated like children. The elderly think about end of life treatment. They discuss it with friends. They discuss it with family. They discuss it with physicians. They do all this over a period of years. There is no reason to start paying physicians to explicitly talk about this every year unless your goal is to pressure the elderly into giving up on life early and to create a societal expectation that the elderly kill themselves off. This is government subsidized psychological coercion of the vulnerable.

      1. Nice! Childish name-calling with very poor reasoning wins every time!

        “coercion of the vulnerable.”

        Can’t forget the vulnerable! MUST PROTECT ‘EM AT ALL COSTS!

        It’s like we’re at HuffPo!

  32. We live an age that assumes resources are infinite and human life priceless. Unfortunately this isn’t quite the case. You have to draw the line somewhere. This bill would probably not have been the right way to go about it though.

  33. Badger seniors yearly into signing a contract agreeing to walk out onto the ice floe when required by government.

    Nice way to cut costs.

    Not only does it cut costs at the end, they’ll start avoiding going to the doctor at all.

    My mother is getting up towards 80. She routinely tells me of salesmen and company representatives trying to brow beat her into buying things. She’s not quite as with it mentally as she used to be, and she knows it. It saps her confidence and assertiveness in these situations.

    Next they’ll be paying docs commission (ahem, administrative fee) when they get seniors to sign documents declining care in certain circumstances.

  34. Die with dignity dammit! Save money.

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  36. Compassionate care–with luck, from a physician–is the ideal.

    Every one of us is part of a nation that educates physicians so that there are among us individuals who are qualified to decide whether our signs and symptoms meet the criteria for any proposed plan of action. This is true whether the patient has signed some form and regardless of on which side of being brain-dead (that is, before the dreaded condition occurs, or after) the patient is.

    By threatening physicians who would otherwise and naturally be prescribing/administering palliatives, the bureaucracy, long ago, was able to gain more than a foothold into the relationship between patient and doctor. It doesn’t matter to some people at which end of another person’s life they begin to take possession of that other person.

  37. The usual complaint from the right about the left is that the left wants to constantly tax and spend tax payers money. Yet now you just as firmly believe that the left has reversed their usual position, and now want to cut government costs and are willing to kill people to do it?

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  39. Have you ever tried to check the sources before just copy and paste this silly nonsence. This story has nothing to do with any religious reasons.It is a shame that you put provoking and deceitful news on your website.

  40. Dr. Singer must be living in the 19th century, or his patients are much better prepared than most to avoid the end-of-life fiasco that is the modern American death. Thousands of dollars wasted on low-yield procedures, approved by foolish children in the desperate hope of a miracle. Then Grandma dies. If she were approached before the crisis, in a routine appointment, she could make better decisions about her own end, but when the endotracheal tube is inserted, that discussion can’t happen. I also resent the hysterical and disingenuous term, “death panel”, which is not descriptive of anything in the public law at this time.

  41. Get government replica uggs out of education and kids will get educated or fake uggs for sale not, as their parents desire. More of them will actually become educated without government than do now with it.

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