Sunday, August 16, 2009

HR 3200 ~ and its the provision for End-of-life planning (Section 1233

HR 3200 ~ and its the provision for End-of-life planning (Section 1233)

August 16th, 2009

I am a conservative Mennonite, parent of 3, grandmother, former ER nurse, currently a professional midwife and appointed member of the Midwifery Advisory Council for the Medical Board of California.

After 4 decades as a healthcare professional and patient advocate, its obvious to me that America can’t afford not to reform the way we provide and pay for healthcare. Rarely has a robust public discourse been so important to the welfare of Americans as the debate on health care reform. In order to fix the long-term deficient, we must fix health care. For American business to successfully compete in the global economy, we must fix health care. In order to live with ourselves, we must fix health care.

However, news programs and cable talk shows opine 24-7 w/o ever actually providing the facts.

Since an intelligent debate requires the facts, I downloaded HR 3200, printed it out, put it in a 3-ring notebook and read all 1,100 pages with my handy yellow highlighter in hand. I now have an informed opinion about the House of Representative’s bill, including the Advance Care Planning Consultation provision (Section 1233).

My husband and I are both retirement age and both covered by Medicare and my mother-in-law in 87. Like every other American, we’d be highly offended by any hint of duplicity in HR 3200.

People need to know that there is absolutely nothing sinister in sec 1233 — no ‘death panel’ for mentally or physically handicapped children, no scheme to save Medicare money by paying healthcare professionals to hand out hemlock to octogenarians. Not a single word in sec. 1233 (or anywhere else in the House bill 3200) even remotely hints at a government-sponsored plan to kill off the elderly or disabled, manipulate medical care providers or force doctors to rat on the end-of-life decisions made by Medicare patients to the government.

It would also be helpful if the public understood that Section 1233 is a provision to amend the Social Security Act written by a Republican Congressman from Georgia. As you know, the law has required hospitals to ask all patients being admitted to a hospital if they have an Advanced Directive for the last 20 years. However, the older provision does not reimburse medical providers for spending their professional time to help people to develop an advanced directive.

Section 1233 would simply permit medical practitioners (physicians, physician assistants and nurse practitioners) to be reimbursed for helping Medicare patients develop a plan for end-of-life care that suits their needs and that of their families. The provision identifies the very broadest range of option, stating that: “treatment … may range from an indication for full treatment to an indication to limit some or all or specified interventions.” It is always the patient that decides what kind of care they want, not the practitioner. Sec 1233 includes training for health care professionals “about the goals and use of orders for life sustaining treatment”. The only role of physicians or practitioners is to provide factual information on the full spectrum of possible choices and how to best achieve those goals, including necessary legal information.

The only thing being tracked and reported by sec 1233 is the level of compliance by the health care professional with their obligation to inform the patient about advance directives and life-sustaining treatments. Exactly how this information is to be measured and tracked is not mandated by HR3200 but comes instead from a “consensus-based organization”. A further safe guard in the bill is a requirement that criteria proposed by the consensus-based organization be published in the Federal Register and a period of public comment provided before it can be adopted.

The facts about the House bill are simple, and straightforward and should be communicated that way in the media:
The Advance Care Planning Consultation provision is thoughtful and well-written
It carries forward the intent of Social Security Medicare legislation of 20 years ago in a professional and effective way
Sec 1233 reimburses health care professionals for helping Medicare patients deal effectively with end-of-life issues thru a process of advanced planning
The information imparted by medical practitioners is to be developed or endorsed by a consensus-based organization and includes a feedback process before being implemented
Since it only amends the Social Security Act, so there is nothing hidden, either in the Sec 1233’s own text or elsewhere in HR 3200.
To make that a bit easier, I posted a plain language version of Section1233 and also included the original uncut version of the same provision for direct comparison. Freed from distracting details and legalese, this plain language text makes it possible to understand what Sec 1233 does and doesn’t say.

Go to and read it for yourself.
Faith Gibson, LM, CPM
Palo Alto, Ca

Wednesday, June 17, 2009

The Revolution Starts Today at 3 pm . . .

This blog is dedicated to the passage of health care-health insurance legislation. The minute President Obama signs a bill that eliminates inefficient systems, wasteful care, failure to treat preventable conditions and the unproductive spending that currently plagues our health care system, this blog will go black and we will be taking a year's Sabbatical from all things political.

But before tackling the daunting political realities and relevant information, a few words about our name. Chokepoint medicine describe the system put in place in 1910 that requires every non-urgent patient to first go thru the eye of a needle to see and be seen by a medical doctor before any other aspect of the health care system can be accessed.

What's the problem with that?

Approximately 90% of all medical appointments are for non-acute healthcare. This category includes mild illnesses, minor injuries and “self-limiting conditions” -- situations that resolve naturally or heal spontaneously. By definition, self-limiting conditions neither need nor benefit from medical technology, prescription drugs or surgery. The illustration often used is that a cold, if untreated, will go away in seven days; if treated, it will go away in one week.

Ordinary, garden-variety complaints include mild illness or injury, psychological issues such as anxiety or mild depression, normal biological states such as pregnancy and well-baby care, life-style issues (diet, exercise, contraception and questions about sexual topics), school and work physicals, vaccinations, testing for STDs, managing a stable chronic disease, etc.

These health concerns are not medically complicated, but can be time consuming and certainly take more than the 6 to 10 minutes allotted for the typically non-urgent medical or OB appointment. What people seeking non-urgent health care most want and need is a relationship with an unhurried primary-care practitioner who is able and willing to be empathetically present, to listen, talk, ask questions, sympathize, make suggestions, and spend whatever time it takes to educate the patient (or parents) about how best to manage their health.

The big question is whether 9 to 13 years of medical school training in the treatment of life-threatening emergencies and the use of drugs and surgery is actually the most appropriate way to provide safe and cost-effective health care for every headache, earache, sniffles, sore throat, tummy ache, backache, athletes foot, trouble sleeping, pap smear, normal pregnancy, healthy child check-up and all the other non-urgent and self-limiting conditions that stack up in a physician’s waiting room every day?

Can this possibly be rewarding way for a highly trained medical doctor to spend his (or her) time? And from the patient's perspective, it must be nearly impossible to get cost-effective services for this kind of routine care from a physician who is trying to pay off a hundred thousand dollars of med school loans and meet staff payroll, office overhead and malpractice insurance premiums.

So how did this mismatch come about?

In the early 1900s primary care was provided by a mixture of MDs, non-allopathic physicians (osteopathic, naturopathic and eclectic doctors) and non-physician practitioners (including midwives). Organized medicine choose to do away with the traditional multi-discipline form of health care and to replace it with an exclusively medical model purposefully configured to have a chokepoint. The decision to get rid of non-allopathic physicians and non-physician practitioners occurred without any prior scientific research and without making any distinction between non-urgent care for everyday self-limiting conditions and urgent medical intervention for serious and acute problems.

In 1904, influential leaders in medical politics knew their plans to close half of all medical schools and make medical care exclusive allopathic were motivated by a political and economical agenda, not science. At the time, there was a glut of medical practitioners, driving down the average income of an MD to little more than the weekly wage of a mechanic. However the AMA, in conjunction with the Carnegie Foundation, promoted these activities as simply a public safety campaign designed to improve medical education and make medical care truly "scientific".

In 1910 the AMA recommended an exclusively allopathic, MD-centric model of health care, which was "adopted" in all over the United States without the public understanding the long-term implications. The immediate consequences was to dismantle the traditional form of healthcare and eliminate women and minorities from the practice of medicine. The public and even other professionals assumed that the AMA used a rigorously scientific method (statistical research and comparative studies) to evaluate the effectiveness of the different health care disciplines. Would it be the traditional multi-discipline model or exclusively allopathic, MD-only care? Or would it be a new collaborative model in which three types of practitioners cooperated with one another and made treatment choices depending on the kind of care the patient required or requested. Whatever was decided, people assumed it would be an evidence-based model known as ‘best practices’.

As we know, no rational process was used in 1910, nor has one been applied in the 99 intervening years. In the last 30 or so years, our MD-centric, authority-based model provided the platform and push-off point for an exploitive form of corporate medicine which has doubled our troubles - a deadly combination of lack of treatment and over-treatment, depending on whether or not you have health insurance.

For those with good insurance, care in an investor-owned, for-profit facilities often means over-treatment. This results in excessive cost to the system, out-of-pocket expense to the patient and increased rate of mortality due to increase interventions. For the uninsured, lack of treatment is fatal condition for 20,000 people every year, a metric that doesn’t count all those living with sever disabilities because timely medical services were unavailable to them. For far too long medical politics has masqueraded as science, and corporate politics has triumph over fiscal responsibility. As we rightly credit medical science with saving lives, so we must discredit medical politics for costing lives.

That brings us back to where we started -- chokepoint medicine -- which is just one piece of a matrix of interlocking problems with our profoundly dysfunctional health care system. However, it is the one that is easiest to remedy – we know what is wrong, and we know what to do about. It’s particularly appropriate at a time when the baby-boomer generation of physicians is retiring at a much higher rate than medical schools are pumping out new graduates.

Time and relationship-intensive care for routine and non-urgent health concerns is most satisfactorily provided by non-physician primary care practitioners – nurse practitioners, physician assistants, professional midwives, naturopaths, etc. This is what they are trained to do and their care is safe, cost-effective and rates high on patients satisfaction. In event of a serious or urgent medical situation or at the patient’s request, primary-care practitioners refer or transfer of care to an MD or emergency facility. This cooperative, collaborative model is where preventive medicine actually starts. It is also how the routine overuse of Rx drugs and procedures is stopped.

Why don't we have a system that facilitates instead of impedes this common-sense approach? Stay tuned, because that is not the only good question that doesn't seem to have a good answer.

Tomorrow's blog will be the beginning of a conversation about what’s happening in the political arena of health care legislation and what critical pieces of information might to prepare us as citizens to better participate in our democratic process.

Charles Wesley Boone, et al