Archive for January, 2011

End-of-Life-Discussion Medicare Insurance

Wednesday, January 5th, 2011

The death-panel demagogues have extorted a rule change from the President, decreasing Medicare-paid access to anticipatory discussions with physicians on end-of-life options.

The gullible people got what they asked for.

However, consider that Medicare-covered health care is scarce, and much beneficial treatment is not paid for, or paid for at dubiously adequate rates. Given that fact, if something were going to be trimmed from what Medicare covers, it might arguably be wise to trim something with a predictable, low, fixed cost. An annual discussion with a physician on end-of-life planning falls into that category. It might cost each of us, say, $30 a year (a 1999 estimate of the cost to Medicare of an add-on skin-cancer screening was $20 per patient), or about $930 million if 2/3 of all Medicare beneficiaries took advantage of the benefit. This is about the same amount as Medicare spent on colonoscopies in 2008. If Medicare were subject to a budget constraint and one had to choose whether to pay for annual end-of-life discussions or for (roughly) decennial colonoscopies, which of these would you sacrifice? I’d expect many patients to forego colonoscopies if not paid for by an insurer, because of the high per-screening cost and the travail of sedation and chaperoning. So my intuitive response to this question would be: Kill the discussion insurance and keep the colonoscopy insurance.

Another argument for a relatively low prioritization of physician end-of-life-discussion coverage by Medicare is that paramedical, social-work, and charity personnel could supply a major part of the service, while the same can’t be said for most of what Medicare covers.

Yet another argument is that you’re not likely to be well-served by having your end-of-life-planning discussions with a physician. Physicians are notorious for being ill- or non-trained about death (or, I should have said, medical schools are notorious for not providing such training), for sweetening their prognoses, and for ignoring patients’ living wills. Perhaps, then, Medicare should encourage consumers to get their end-of-life-planning advice from outside the medical profession.

So, given that the President is willing to play symbolic games of compromise, it seems to me that his choice of what to sacrifice can be defended.