Thursday, August 13, 2009

Kathleen Parker in the Monkey House

Talk about no good deed going unpunished! For several years, a bipartisan coalition of legislators has introduced various bills that would provide a tiny expansion of Medicare coverage: authorizing reimbursement for "advance care planning consultations." These are sessions in which a physician counsels patients about end-of-life topics such as hospice care, living wills, and life-sustaining treatment orders.

Many physicians already provide such consultations, and some are reimbursed by private insurance. But for Medicare patients, the availability of this advice is dependent on the charity of overworked primary care physicians, or the ability of community organizations to provide it free of charge. Proposed legislation that would have reimbursed such consultations under Medicare was introduced on a bipartisan basis in 2007 (S.465 and S.466) and re-introduced this year (H.R. 1989, H.R.2911, and S.1150).

And then.

The Medicare reimbursement provision got rolled into Section 1233 of America's Affordable Health Choices Act of 2009, the massive healthcare reform bill currently before the House of Representatives. And as quickly as you can say "insane industry-generated talking points," screaming protesters at town hall meetings were denouncing Section 1233 as a program of mandatory euthanasia-promotion straight out of Kurt Vonnegut's "Welcome to the Monkey House."

The accusation is pure madness, of course, one to which no responsible journalist would give credence, right? Ah, but enter Kathleen Parker, professional Moderate Conservative and reasoned editorialist for the Washington Post Writers' Group. In an August 12 column, Parker sets her trademark tone by opening with "We do need to turn down the rhetorical heat... let's assume that no one wants to kill off old people." But then she explains that "the debate is over whether these consultations are conclusively voluntary -- and the bill... is vague enough to cause concern."

Parker's evidence that the bill is murky on whether G-men will haul Granny to the Ethical Suicide Parlor for a "consultation"? (1) Medicare would pay for consultations every five years, except more frequently if a patient's condition has worsened; (2) The consultation could include formulation of "an order regarding life-sustaining treatment"; (3) Depending on state law, nurse practitioners and physician's assistants could be reimbursed for these consultations; and (4) The Secretary of Health and Human Services would be required to develop "quality measures" on end-of-life care and advanced care planning. Yes, I'm leaving out the nuance of Parker's argument. Yes, you should read the column for yourself to see how she connects the dots. No, it won't make any more sense.

Of course, Parker is not saying that Section 1233 really mandates pro-suicide rap sessions at the adult day center, just that "people instinctively (and correctly) fear bureaucracy -- especially in matters of life and death... and have a right to demand clarity." To paraphrase Hillary Clinton on Obama's secret devotion to Islam, Parker is telling us that Section 1233 isn't really about killing seniors, as far as she knows.

Fortunately, Parker has a solution: "A simple amendment to HR 3200 would do much to cool tempers. All that's needed is specific language saying that these end-of-life consultations are not mandatory -- either for physicians or patients -- and that there would be no penalty, either in coverage or compensation, for declining to participate. In the absence of such language, one may reasonably assume otherwise."

No, Kathleen, one may not reasonably assume otherwise. Point me to an instance in which the Medicare reimbursability of a service has been interpreted to make that service mandatory, and maybe you'll convince me. And while you're at it, explain to me how Congress could enact your proposed amendment without simultaneously amending every other provision of the Medicare statutes to clarify: "this service is not mandatory, either."

Besides, if the anti-reform bloviators paid attention to their own rhetoric, they'd realize they have little to worry about. Most of the enforced euthanasia will never happen. Like all other medical services, it will be "rationed" by the "bureaucrats who come between you and your doctor." It's like the borscht belt gag about the restaurant: "the food was terrible -- and such small portions!"

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