This Saturday every American has the opportunity, like we do every day, to take steps to ensure that our wishes regarding future health care wishes are honored.  National Healthcare Decisions Day is now in its 4th year!  This is a chance to think through your values regarding your health care, and to choose the person you would trust to make decisions on your behalf if you were ever incapacitated to the point that you could not express yourself.  As a physician, I deeply appreciate when my patients have taken this important step.  Once you have chosen your trusted person, have a conversation with them about what is important to you when it comes to your health, particularly if you were to face a serious accident or health crisis.  Then, complete Power of Attorney for Health Care paperwork to officially authorize this person to make decisions on your behalf.  (Link is specific to my home state of NC).  Finally, thank your Power of Attorney for their willingness to play this important role!

For more information (and for links to other states’ forms) visit NHDD.org.

April 16th is National Health Care Decisions Day.  When a health crisis occurs, many individuals and families are unwillingly thrust into a situation where a difficult decision must be made, and the values or preferences that would guide that decision were never discussed.  Don’t let this happen to you.  Take time to choose your power of attorney for health care, the one person you would trust to make decisions about your health care on your behalf if you were ever unable to express those wishes.  Let that person know that you would be honored if they would play that role for you.  Talk with them about what is important to you if you ever encounter a scenario in your own health where you cannot verbalize your wishes.  You don’t even have to discuss specifics, but it may help that person if they know what type of approach you would want if you were in that situation and you had very little hope for recovery.  Then, complete the Durable Power of Attorney for Health Care form.  It can be downloaded here.  Make copies for your power of attorney, yourself, and give one to your doctor and anyone else you think should have a copy.  If you need help, make an appointment with your doctor to specifically discuss this issue.

My thanks to Janet Parshall and Talking it Over for a great conversation today about protecting the rights of conscience for health care workers.  The best source of information that I have found on this issue is Freedom2Care.  Visit this website to learn more about this important issue and to find out what you can do to ensure that our health care system preserves your right to receive care from a physician or health care worker who is freely able to practice according to their deeply held beliefs, whatever those may be.

Oregon recently launched a state registry for patients who sign a form known as POLST (Physician Order for Life-Sustaining Treatment).  This transferable order set allows patients to give specific instructions on the treatments they would or would not want in certain situations.  For example, a patient may opt for or against resuscitation for cardiac arrest, for or against IV antibiotics, or whether or not to place a feeding tube in different scenarios.  The POLST orders go beyond most states’ DNR (do not resuscitate) orders, which only apply in the event of cardiac arrest.  POLST allows a patients to direct their care even when they have become to ill to express their wishes.

One of the biggest problems with advance directives is that emergency crews or hospital staff cannot locate the documents in a crisis, the time when the expressed wishes are most crucial.  Unless medical personnel have a verbal or written directive from the patient, we are obligated to perform certain procedures like intubation and mechanical ventilation, which many terminally ill patients do not want.  POLST tries to ensure that wishes are honored, but even in states where POLST has been implemented, relying on a paper form has its risks.  This program in Oregon would allow medical personnel with a password to instantly access the POLST record electronically, even if the paper document cannot be found.  Many times I have encountered situations when a patient was in a crisis, unable to speak, and we could not locate the advance directive or power of attorney.  Too often the patient had something done that went against his or her expressed wishes, simply because those expressions were not available when needed.

I understand concerns that people may have about an electronic record of private and personally held wishes that can be used to direct medical care.  I believe that this system would give more control to patients, not less.  If you take the time to document your wishes, shouldn’t they be available to health care personnel in a time of crisis?  The registry is purely voluntary; Oregon residents are not required to participate. There is no coersion to choose one option over another; patients may direct care however they see fit, even to request all available treatments or procedures be given under any circumstance. While I do not agree with Oregon’s policy on legalized physician-assisted suicide, I believe that a voluntary electronic registry of patient wishes is a helpful addition to the health care system, and I hope that more states adopt such a program.

As I have said before, the best way to ensure that your wishes are honored is to name a Power of Attorney for Health Care.  Read more here.

I have blogged before about the importance of sharing your end-of-life wishes with someone you trust.  Thanksgiving is the perfect time to have that conversation as you gather with family.  The fine folks at Engage with Grace have put together a slide of 5 questions that will make this process easier.

If you have the gizzards to bring up these questions at the Thanksgiving dinner table, you deserve the Myles Standish Award for Bravery.  Even so, I find that once the ice is broken, these conversations can be quite cathartic, and you and your family will feel like you accomplished something important at Thanksgiving besides overloading on poultry and dozing off into a tryptophan-induced haze.  So, after you engage with gravy, Engage with Grace this holiday.  You can thank me later.

…would love to hear your comments on how it goes…

Today’s article by Barbara Brotman in the Chicago Tribune gives an excellent representation of what advance care planning conversations might look like at the end-of-life. Of course, advance care planning can occur at any stage of illness, and does not always have to address things like Do-Not-Resuscitate orders or refusing other invasive measures. It could simply cover what you value when it comes to your health care, and who you want for your Power of Attorney.

The article also explains more about Someone to Trust and what we are trying to accomplish in Chicago.

Have you heard the radio advertisements for legal firms that will send you a FREE living will? Have you heard them promise that if you call now, you can save even more money because they will include a FREE Health Care Power of Attorney? Sounds great, doesn’t it? What they don’t mention is that these documents are already available for free, and you don’t even need a lawyer in order to complete them.

The most important advance care planning document, and the one everyone should have regardless of age, is the Durable Power of Attorney for Health Care (DPAHC). This is the document that names someone to make decisions on your behalf if you ever are in a situation where you cannot express your own wishes. Most people, when asked, know immediately which person they would trust in that situation. It is important to name this person in writing, because state laws vary, and without the proper paperwork, it is possible that someone other than the person you want would have authority over your health care if you could not express yourself. For example, I recently admitted a patient to the nursing home whose granddaughter cared for her at home for many years. The patient had become very ill and could no longer express her own wishes, but she had expressed her wishes to her granddaughter during previous conversations. Unfortunately, they never completed a Power of Attorney for Health Care. The patient’s estranged son arrived on the scene and began to demand a course of management that went against the patient’s wishes. In spite of the granddaughter’s protests, the nursing home was obligated by law to follow the wishes of the son, because Illinois law gives adult children priority over grandchildren for decision making authority when there are no papers. Such a scenario could have been avoided had my patient completed her DPAHC and named her granddaughter.

If you live in my home state of Illinois, the official DPAHC form can be downloaded for free here. Most other states make their forms available as well, and you can find them by doing a web search for “(your_state) power of attorney for health care”. Once you have the form, you simply need to identify your person of choice, fill in their name and contact information, and sign the form. In Illinois, you will need one witness to also sign the form. You don’t need an attorney, and you don’t need a notary public. You don’t even have to have your decision-maker sign the form. I still recommend this, because the person you choose needs to know of the important responsibility you have given them.

There are other sections of the form that allow you to express specific wishes, such as a procedure you definitely would or would not want, or specific organs you would want donated. It is not necessary to fill out these portions, though it may be helpful for your decision making agent to know this information. However, he or she is not obligated to follow what is written there. That is why the best approach is to have a conversation about your wishes with the person you trust. This will give them the opportunity to ask you questions and to see and hear directly from you what is most important about your individual wishes.

Another advance directive is the living will, which gives you the opportunity to state that you would not want to be kept alive artificially if you contracted a terminal illness and doctors believed you had no hope of recovery. This document also gives you the opportunity to define specific courses of action. I have run into problems with this document and I do not find it as useful as the Power of Attorney. One problem with the document is that you can fill it out and never tell anyone. If you were to become very ill, unless someone has a copy of your living will, it may never be followed. It is much more powerful to have a living, breathing advocate (your Power of Attorney for Health Care) who understands your wishes and can help guide your doctor through the myriad of possible scenarios that can occur if and when you become ill. I do not have a living will, but I do have a Power of Attorney for Health Care. I know the President told us recently that he and his wife have a living will, and that it is important to have one, but I think it is far more important to have your Power of Attorney for Health Care.

Once you have filled out your advance directive, keep a copy for yourself, give a copy to your decision maker, and give a copy to your doctor. There is a movement to standardize these documents and make them more accessible across health care systems. In Chicago, a large coalition called Someone to Trust is working to accomplish this goal for the first time in a large, multiethnic city. Google Health recently added a section where you can scan and store these documents so you can authorize your agent or doctor to access them in time of need. If you feel comfortable using this service it is a good resource.

For more information on Advance Care Planning, visit the website for National Health Care Decisions Day.

Today while driving between nursing homes, I heard Rush Limbaugh talking about the health care reform bill’s Advance Care Planning Consultation section. He, like some other conservative talkers, was complaining that the government was mandating these consultations as a way to usher patients towards an early death in order to save money. In my previous post I explained why this was an unfair characterization of Section 1233, and that it makes sense to reimburse doctors for the time they spend talking with patients and families about their health care wishes. I decided to call in, and I actually got through. “Dave in Chicago, you’re next..” Rush said.

I explained that I was a physician, and that there are many aspects of the current health care reform bill that I disagree with, but that this provision was actually a good idea. I said that I often take extra time to ask my patients about choosing their power of attorney and about their end-of-life care wishes, and that it was smart of Medicare to encourage these conversations by providing a small reimbursement to doctors who initiate such discussions, since the current structure requires doctors to essentially offer this service for free. I started to explain that the bill actually does not mandate these conversations between doctors and patients, nor does it mandate their content. Then I realized that Rush was talking and my voice was turned off. He once again incorrectly insisted that the bill will mandate a consultation promoting “death care,” a term he claimed I had used. He said that I was welcome to have those conversations with my patients, but that anyone who had a doctor like Dave in Chicago who insisted on talking about “death care” should find a new doctor. I tried to protest but quickly realized that my voice was turned off and that our “conversation” was over.

Rush Limbaugh’s reaction to my call was a stark reminder that many people completely misunderstand palliative medicine and end-of-life care. While he railed on about doctors being mandated to discuss death with their patients, I could sense an underlying fear, perhaps about his own mortality. Death is inevitable, and one of the greatest gifts I can give my patients is to help them look ahead to possible scenarios and to express their thoughts and wishes about their medical care while they are still able. Those of us who practice this skill do not attempt to usher our patients toward an early death for the sake of utilizing fewer health care dollars. All too often I have watched patients and families undergo painful and invasive treatments which are unlikely to extend life or provide any healing, simply because they felt they were obligated to submit to such treatments. No doctor had ever laid out the real picture, that their prognosis was poor and their choices were limited by their disease. They needed to hear that their realistic options had shifted away from the best course for avoiding death to the best way to maximize the quality of life remaining. They needed to know that there was another path, and they probably needed to hear that from a doctor. Many doctors avoid these conversations because they are uncomfortable or awkward. Doctors who talk about death with their patients are brave.

I do understand the fear that more government-sponsored health care will lead to rationing and could result in seniors being denied services simply because of their age. That is a real concern. It is a reason I am not in favor of more government involvement in health care. However, please do not make the same mistake Rush Limbaugh made today and equate coversations about end-of-life care with promoting “death care.” Expressing your wishes to your doctor, and asking about options if and when you become ill, serves to promote patient choice and control, not take away from it. I still think government-run health care is a bad idea, but as long as Medicare pays for most seniors’ health care, I think it is admirable that they are looking at ways to make it easier for doctors to assist their patients with advance care planning.

Part of the proposed health care reform bill that I like is the idea to reimburse physicians for having an “advance care planning” discussion with their patients once every 5 years. This is something I do with my patients often, and I have wished many times that Medicare would recognize the value of this skill, and the time it takes to perform it, by offering specific reimbursement for the discussion. Unfortunately, some Republicans are saying that supporting a patient-physician conversation about goals of care and end-of-life options will “start us down a treacherous path toward government-encouraged euthanasia“. I disagree.

Section 1233 of HR 3200, the proposed health care bill, is titled “Advance Care Planning Consultation”. It allows a physician to be reimbursed for leading his or her patient in a discussion about the patient’s wishes in certain medical situations. I find these discussions to be very helpful for patients and doctors. Patients have the chance to think through different scenarios and ask questions about what to expect. They also have the opportunity to put these wishes in writing, and to select a surrogate decision maker for a situation in which they are unable to express their own wishes. Doctors can gain insight into their patient’s preferences so that, when they become ill, the doctor knows better how to care for them. Family members are often involved in these discussions, and the process helps prepare the entire family for unexpected events so they don’t have to panic in a crisis. These discussions often occur around the time of a new diagnosis, a serious change in condition, or a change in living situation such as a move to a nursing home.

The bill does not mandate these discussions, as some commentators and even congressmen have suggested. It simply rewards clinicians for taking time to assist their patients with advance care planning, if they chose to do so. The bill also does not mandate the specifics of the conversation. It mentions many of the standard treatments that are discussed in an advance care planning session, such as intravenous antibiotics, artificial feeding and hydration, and hospitalization. The bill does not mandate what is said or decided about these issues; it simply allows that they can be part of a conversation that would qualify as advance care planning.

My only concern about a bill like this is that it recommends: “An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title”. I am a staunch supporter of palliative care and hospice, when appropriate, but in states where physician-assisted suicide (PAS) is legal, the phrase “continuum” could be used to mandate that physicians offer this option to their patient in any advance care planning discussion. However, the bill states that this discussion can include such an explanation, not must, so the bill as it is currently written would not mandate offering PAS even where it is legal.

Though I have many problems with HR 3200, and I hope it does not pass in its current form, I am encouraged that reformers are recognizing the value of advance care planning, and that they are considering reimbursing physicians for taking time to providing this valuable service to their patients.

I don’t have all the answers to health care reform. American medicine is a complicated web of economic, political, and social factors. I believe that everyone engaged in this debate wants the best health care for the most people; we just disagree about how to accomplish that goal. President Obama’s recent statements about Medicare tipped me off that he is about to damage our health care system in ways that may not be reversible.

Medicare Advantage- standard or scapegoat?
His comments were about the program called Medicare Advantage. This is a program that works like an HMO. Patients who are Medicare-eligible enroll and reassign their Medicare benefits to an insurance company. The government then pays the insurance company a set amount per month to manage that patient’s health care. Patients pay lower premiums (regular Medicare still requires patients to pay 20% of most of their own health costs), and patients must navigate their medical care through their primary care physician, who oversees everything and generates referrals for procedures or visits to specialists.

The insurance company contracts with doctors and hospitals to provide the care. If they do a poor job of efficiently managing a patients’ medical care, they lose money. Let’s say Medicare pays $700 per month for a patient. If that patient ends up having a $3000 hospitalization that month, the insurance company loses $2300 (and often passes that loss along to the doctors and hospitals in the form of reduced reimbursements). If, however, the doctors keep their patients healthy and out of the hospital, or help them avoid invasive (and therefore expensive) procedures, they have money left over at the end of the month. The doctors and hospitals who figure out how to manage their patients’ care at the lowest cost have an incentive to do so. For example, if I meet certain clinical goals with my Medicare Advantage patients (things like improved blood sugar readings for my patients with diabetes, improved blood pressure readings, timely immunizations, etc), then I will qualify for a year-end bonus from my employer, Advocate Health Care. If I don’t help my patients meet these goals, then no bonus for me.

For those who are concerned that this arrangement motivates doctors to withhold care, one of the largest factors we measure is patient satisfaction. Our scores go down if our patients’ satisfaction goes down. Also, because there are many insurance companies, doctors and hospitals who accept Medicare Advantage, patients who are unhappy with their treatment can always switch providers. Another potential concern about this program would be that insurance companies will only accept healthy patients under this arrangement, but Medicare adjusts payments based on diagnoses and severity of illness, in order to encourage providers to take all patients, both healthy and sick.

The bottom line: Medicare Advantage sets a goal for health care costs, and then encourages doctors, hospitals, and insurance companies to work together to stay within that cost. Those who do it the best will keep more patients and will see financial benefits at year’s end.

Obama’s flawed philosophy

Here’s where President Obama comes in. He wants to eliminate Medicare Advantage. His reasons reveal what I believe to be a flawed philosophy towards our health care system. According to Obama, Medicare Advantage “overpays insurance companies” and leads to “wasteful spending.” Here’s what irks me about that. Let’s say that Medicare pays a capitated rate of $500/month per patient to the insurance/doctor team. (This is an oversimplification, but works for the sake of example). And then let’s say that I work hard to keep my patient’s healthcare costs to $400/month. I do this by spending more time with my patients emphasizing prevention, making extra phone calls to make sure their treatment is working so they don’t end up in the ER, and arranging for family meetings to discuss advance care planning so patients avoid unwanted treatments and procedures. The resulting $100/month cost savings is my financial incentive to control my patient’s costs. In many ways, it makes it possible for me to spend the extra time, since Medicare does not directly reimburse for phone calls or family meetings. What bothers me is that President Obama looks at the cost per month for this patient and thinks the $100 is “wasteful”. He naively assumes that the patient’s costs could have been managed within $400/month under regular Medicare, that pays according to what doctors/insurance companies bill (the “fee-for-service” model). He sees Medicare paying $500/month when they could have just paid $400. He fails to realize that my patient’s lower cost per month was the result of my hard work, which was motivated, in part, by the opportunity to earn some extra money for being efficient and effective. When Obama labels this financial incentive as “wasteful” and “overpayment” he suggests that doctors, hospitals and insurance companies should be expected to control their patient’s costs with no additional incentive for doing so. In today’s world of declining reimbursements and increasing malpractice insurance rates, this is an unreasonable expectation.

By President Obama’s own admission, any financial profit gained by health care providers who manage their patients well and keep costs down is considered “wasteful.” His comments reveal a philosophy that resists, and may even resent, any financial gain by those who succeed at providing health care efficiently. This philosophy demonstrates a gross misunderstanding of human nature. It is a philosophy that could damage, and perhaps destroy, America’s excellence in health care.

One factor more than any other has made American innovation in health care the envy of the world. That single factor is competition. Here in the USA, the business entity that does anything better than its competitor will achieve success. Competition drives creative solutions in all fields, including health care. The hospital that provides the best care at the lowest cost will end up with patients lining up outside its doors. The pharmaceutical company that invents a drug easier to take, and with better results, will take over the market. The medical school that develops innovative training techniques will get the best and brightest applicants. There is nothing obscene about success in a health care market; indeed, it is the potential for success that drives new innovators to enter the field and achieve personal goals, financial or otherwise, while improving health care for patients.

President Obama must understand human nature enough to understand this. Very few enter the health care field (or any field) on purely altrustic motives. There is always an underlying desire for personal success in the field that one loves. Yet, Obama naively labels financial incentives in health care as “wasteful” and “excessive.” These statements frighten me, as Obama pushes for health care reform. Introducing more government into health care will skew the competitive market away from free enterprise, away from opportunities to develop innovative solutions, and towards more paperwork, beauracracy, and waste. The nursing home environment, where I spend the majority of my time, is one of the most heavily regulated sectors of health care. I am not against regulations; some rules are necessary to protect the vulnerable. However, the efforts required of doctors, nursing home staff, and administrators, in order to keep up with the documentation for state and federal regulations, drains nearly all of the patient-focus out of daily care. Nursing home employees are often more concerned about keeping their charts and documents within regulations than they are about caring for their patients. This is not a knock against nursing home staff; they are some of the most caring people I know. This is simply an example of what a large beauracracy does to any industry.

Stop cursing profits
Any health care reform must preserve the opportunity for people and organizations to compete on a level playing field in the health care market. The introduction of a wide-reaching “public option” for health insurance will, by its nature, limit these opportunities. Government subsidized health care will not be under the same pressure as private health care providers. Private companies must generate a profit in order to survive. This forces people to work hard, innovate, and contain costs. Governments that can simply print or borrow money do not need to generate profits. There is no pressure to perform well. This leads to laziness and lack of care, and costs tend to expand. President Obama should stop cursing insurance companies and innovators who earn money by introducing solutions into the health care market. He should not naively assume that injecting more government into health care will somehow bring equality and order. I believe it will have the opposite effect. I believe more government involvement in medicine will reduce health care quality for most Americans, will ultimately limit access to care for most Americans, and will discourage our best and brightest from entering the field of medicine. I hope and pray that the administration and Congress take a measured approach before increasing federal involvement in health care, because once government expansion occurs, it is very difficult to retract.