Friday, August 14, 2009

Advance Directives: An Achilles Heel to Health Reform

How about former Vice Presidential candidate Sarah Palin and her 'rationing' by 'death panels?' She's on the topic thicker than the carpet in a hospital lead administrator's office.

Which is why the Disease Management Care Blog is taking this opportunity to categorically deny that it advised the Republican opposition that the topic of advance directives was an Achilles heel for health reform. It knew this early in the debate because of its experience with the Patient Self Determination Act (PSDA). This 1990 law required a number of health care entities - including HMOs - to provide information to patients about end-of-life care. This was something the DMCB knows about and, back in the day, the DMCB's managed care boss asked it to help make sure our HMO was in compliance.

The DMCB ultimately advised that we become minimally compliant. The more we wrestled with the topic, the more creepy it appeared. We felt uncomfortable with the specter of a health insurance company promoting living wills. Even though 1) the intent was honorable and 2) living wills do not equal choosing to die, we thought the appearance of a conflict of interest to the average enrollee was too risky.

The DMCB understands the current version of the House bill only authorizes payment to providers for the the work effort of discussing living wills with patients and requires the Secretary to create a measurement system to see how well this is working. However, it also knows that much of the Miami-to-Minnesota variation in health care observed by the folks in the Dartmouth Atlas really is based on data on the cost and outcomes in the time prior to death. This undoubtedly informed Congress' thinking on the subject.

Imagine what it would be like to have your homeowner's insurance company contact you on the merits of foreclosure. Or making your car insurance company send you paperwork on cash for clunkers. Or making sure beneficiary of a life insurance policy - like the DMCB spouse - brings up the topic of a living will after any life insurance upgrade.

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