Stewart v. McCaughey
I really enjoyed the last Daily Show before their 3 week break. Not because of Jon Stewart - he's usually good but I actually think he was wrong about a lot of stuff and didn't do well even when he was right. I liked his guest Betsy McCaughey. I ended up watching the entire interview twice all the way through, not counting extensive rewinds and replays, because I wanted to make sure I knew what she was saying and whether she was on to something.
What Orly Taitz is to Obama's birth certificate McCaughey is to the national health care "death panels". I expected her to be somewhere between Orly and the average hitler-sign-waving loony and make about as much sense, but she was actually fairly reasonable and coherent. I actually ended up agreeing with her, even, about everything except whether what she was describing was a problem.
"Problem" 1: end-of-life counseling
Page 432 of the health care bill incentivizes doctors to have end-of-life discussions with their patients. McCaughey is trying to conflate "incentivized" and "mandatory" but either way this is 5000% good. Everyone is squeamish about dying, but we're all going to die, and it's an incredibly important topic to consider while your mind is in good enough shape to handle that discussion. But people don't, which means you end up doing a lot of things by default rather than by design or decision. That it's barbaric and horrifying is more than enough. It also costs money but that doesn't even need to be added to the equation. I'd support these discussions even if they were free or cost extra.
Jon and McCaughey seemed to agree that the doctor wasn't going to (and shouldn't try) to sell anyone either on withdrawing life-sustaining treatment or keeping it going. They just need to discuss it. The patient (not doctor) needs to decide which life-sustaining treatment options they want or don't want while they've still got a clear head and ample time to think it over. This seems totally, uncontroversially fine. Terry Schiavo is free to sign up for everything and Christian Scientists are welcome to refuse everything. It would be a problem if there were any incentive for doctors to be rewarded for pushing patients toward withdrawing end-of-life care, but there isn't.
Even though it's just a discussion, McCaughey seems to have a problem with the discussion being encouraged by the government. "Paying doctors to go through a consultation that's prescribed by the government … they prescribe what as to be discussed." FactCheck says it's not mandatory and Stewart says "that would be wrong if that's what it says". Even if it were I still don't have any more of a problem than if a dental care bill made "what are we going to do when food gets stuck in our teeth" discussions mandatory. It's going to happen and we should talk about it. I also don't have a problem with the government or their "consensus-based organization" of choice making sure that all the situations and life-sustaining treatment options are covered because you might as well have a thorough discussion. You can discuss extra stuff, like what happens if the patient is gored by a unicorn, but the government says cover the basics. Good.
"Problem" 2: physician ratings
Systems don't work if they don't provide incentives. The health care bill intends to incentivize good doctors by paying them more than worse doctors. The quality rating will be determined by "data on quality measures for covered professional services". One of those measures is the "creation of" end-of-life plans, whatever those plans happen to be (see above) which seems good to me as I've said. The other is "adherence to" these end-of-life plans. Here's where things get tricky.
I can see an argument in favor of judging doctors by the compliance of their patients. You don't want doctors just paying lip service to this obligation so that they can check a box. You want them to actually explain the issues in a way that helps their patients actually understand the problem and make a choice that they can live with. And the way you can tell whether they've seen eye to eye with their patients is whether those patients end up being surprised and changing their mind. That makes sense to me.
But I can also see a little bit of something on Betsy McCaughey's side. It at least seems plausible (can we see some studies?) that more people are comfortable saying "pull the plug on me" in theory but ask to remain plugged in when death is imminent. And it's possible that doctors will attempt to pressure their patients into complying with their original choices to preserve their quality ratings. "Putting pressure on doctors .. to penalize them if their patient or family changes their mind about their living will is really wrong." I see that point.
What I don't see is a solution with a better marginal benefit. Not rating doctors would be worse. Not incentivizing doctors would be worse. Not having end-of-life discussions would be worse. I'd rather see some patients pressured than all patients uninformed. I'd rather see a relatively small number of dying patients unnecessarily unplugged than a huge number of patients being unnecessarily and very expensively plugged because nobody wants to even talk about it. This seems like the most pragmatic solution. If anyone's got an even better solution that provides public health care, lets us have the discussion about when patients can choose to end it, rewards doctors who have those discussions, and penalizes even fewer otherwise reasonable people who change their minds I am all ears.
Update: As cdk pointed out "orders for life-sustaining treatment" has always, at least in our experience and understanding, meant a living will or DNR order. Those documents only matter when the patient is no longer capable of making choices, at which point one of the doctor's duties is making sure the request is followed. Because sometimes it's not. Sometimes relatives come in and start making choices, and sometimes the order is just misplaced or ignored. So although I would see a problem with a doctor trying to pressure a patient into signing a DNR order, I don't see a problem with a doctor being incentivized to follow their plan and resist the pressure of meddling relatives on either side. If you want to stay plugged in your spouse can't unplug you, and if you want to get unplugged your spouse won't keep you plugged in.
Aside 1: This still has absolutely nothing to do with "death panels". At worst patients are being held to their own decisions, not having those decisions imposed on them by anyone else. Anyone who shows up to a town hall meeting concerned about the government killing their grandma or retarded son is just totally, completely off-base fantasy.
Aside 2: McCaughey seems to have made a bit of a career distorting the words of Daschle and Ezekiel Emmanuel, and with a record like that I'm inclined to be skeptical of any new stuff she says.
Further reading: Part 1, 2. Also PolitiFact, FactCheck, and the AARP are less charitable to McCaughey than I am, and FactCheck responded to her "spot check" dig.
What Orly Taitz is to Obama's birth certificate McCaughey is to the national health care "death panels". I expected her to be somewhere between Orly and the average hitler-sign-waving loony and make about as much sense, but she was actually fairly reasonable and coherent. I actually ended up agreeing with her, even, about everything except whether what she was describing was a problem.
"Problem" 1: end-of-life counseling
Page 432 of the health care bill incentivizes doctors to have end-of-life discussions with their patients. McCaughey is trying to conflate "incentivized" and "mandatory" but either way this is 5000% good. Everyone is squeamish about dying, but we're all going to die, and it's an incredibly important topic to consider while your mind is in good enough shape to handle that discussion. But people don't, which means you end up doing a lot of things by default rather than by design or decision. That it's barbaric and horrifying is more than enough. It also costs money but that doesn't even need to be added to the equation. I'd support these discussions even if they were free or cost extra.
Jon and McCaughey seemed to agree that the doctor wasn't going to (and shouldn't try) to sell anyone either on withdrawing life-sustaining treatment or keeping it going. They just need to discuss it. The patient (not doctor) needs to decide which life-sustaining treatment options they want or don't want while they've still got a clear head and ample time to think it over. This seems totally, uncontroversially fine. Terry Schiavo is free to sign up for everything and Christian Scientists are welcome to refuse everything. It would be a problem if there were any incentive for doctors to be rewarded for pushing patients toward withdrawing end-of-life care, but there isn't.
Even though it's just a discussion, McCaughey seems to have a problem with the discussion being encouraged by the government. "Paying doctors to go through a consultation that's prescribed by the government … they prescribe what as to be discussed." FactCheck says it's not mandatory and Stewart says "that would be wrong if that's what it says". Even if it were I still don't have any more of a problem than if a dental care bill made "what are we going to do when food gets stuck in our teeth" discussions mandatory. It's going to happen and we should talk about it. I also don't have a problem with the government or their "consensus-based organization" of choice making sure that all the situations and life-sustaining treatment options are covered because you might as well have a thorough discussion. You can discuss extra stuff, like what happens if the patient is gored by a unicorn, but the government says cover the basics. Good.
"Problem" 2: physician ratings
Systems don't work if they don't provide incentives. The health care bill intends to incentivize good doctors by paying them more than worse doctors. The quality rating will be determined by "data on quality measures for covered professional services". One of those measures is the "creation of" end-of-life plans, whatever those plans happen to be (see above) which seems good to me as I've said. The other is "adherence to" these end-of-life plans. Here's where things get tricky.
I can see an argument in favor of judging doctors by the compliance of their patients. You don't want doctors just paying lip service to this obligation so that they can check a box. You want them to actually explain the issues in a way that helps their patients actually understand the problem and make a choice that they can live with. And the way you can tell whether they've seen eye to eye with their patients is whether those patients end up being surprised and changing their mind. That makes sense to me.
But I can also see a little bit of something on Betsy McCaughey's side. It at least seems plausible (can we see some studies?) that more people are comfortable saying "pull the plug on me" in theory but ask to remain plugged in when death is imminent. And it's possible that doctors will attempt to pressure their patients into complying with their original choices to preserve their quality ratings. "Putting pressure on doctors .. to penalize them if their patient or family changes their mind about their living will is really wrong." I see that point.
What I don't see is a solution with a better marginal benefit. Not rating doctors would be worse. Not incentivizing doctors would be worse. Not having end-of-life discussions would be worse. I'd rather see some patients pressured than all patients uninformed. I'd rather see a relatively small number of dying patients unnecessarily unplugged than a huge number of patients being unnecessarily and very expensively plugged because nobody wants to even talk about it. This seems like the most pragmatic solution. If anyone's got an even better solution that provides public health care, lets us have the discussion about when patients can choose to end it, rewards doctors who have those discussions, and penalizes even fewer otherwise reasonable people who change their minds I am all ears.
Update: As cdk pointed out "orders for life-sustaining treatment" has always, at least in our experience and understanding, meant a living will or DNR order. Those documents only matter when the patient is no longer capable of making choices, at which point one of the doctor's duties is making sure the request is followed. Because sometimes it's not. Sometimes relatives come in and start making choices, and sometimes the order is just misplaced or ignored. So although I would see a problem with a doctor trying to pressure a patient into signing a DNR order, I don't see a problem with a doctor being incentivized to follow their plan and resist the pressure of meddling relatives on either side. If you want to stay plugged in your spouse can't unplug you, and if you want to get unplugged your spouse won't keep you plugged in.
Aside 1: This still has absolutely nothing to do with "death panels". At worst patients are being held to their own decisions, not having those decisions imposed on them by anyone else. Anyone who shows up to a town hall meeting concerned about the government killing their grandma or retarded son is just totally, completely off-base fantasy.
Aside 2: McCaughey seems to have made a bit of a career distorting the words of Daschle and Ezekiel Emmanuel, and with a record like that I'm inclined to be skeptical of any new stuff she says.
Further reading: Part 1, 2. Also PolitiFact, FactCheck, and the AARP are less charitable to McCaughey than I am, and FactCheck responded to her "spot check" dig.