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The Public Option Death Panel

by Fran Johns

Here’s a death panel even Sarah Palin could love — but maybe we’d better not tell her. You, however, will probably understand its value and possibly want to put it to work for your own benefit. It centers around a form called POLST, for Physician Order for Life Sustaining Treatment (in New York it’s MOLST, for Medical Orders) fast catching on across the country. The panel consists, essentially, of your doctor and yourself.

Initially developed in Oregon in 1991, POLST programs are underway in a handfull of states including Washington, California, New York and North Carolina, and are being developed in over a dozen others.

Erin Henke, POLST Program Manager for the California Coalition for Compassionate Care, outlined the program for a group of healthcare professionals this week in San Francisco, part of CCCC’s efforts to get it efficiently established across the state. The key, she emphasized, is the conversation between individual patient and medical professionals. You don’t get the form signed, in other words, unless and until patient and physician have discussed what the former wants: CPR if you’re not breathing? Feeding tube? Comfort care only, if you’re in bad shape, but you’ve got a pulse and are breathing? Or perhaps every intervention possible — tubes, wires, ventilators, the works, including transfer to a hospital intensive care unit. But the point is, you make your own decisions. Once the form is completed and signed, it follows you as part of your medical record. In California it’s printed on Pulsar Pink card stock, and not easy to overlook.

Rollout of the program, Henke explained, is an ongoing process; it will only work when it is widely known and understood not only by individual patients and physicians but also by the many other members of the profession — nurses, caregivers, ER personnel and others. CCCC’s focus right now is on skilled nursing facilities and hospitals, though Henke and the teams of POLST program advocates around the state are working toward a broad educational spectrum.

The basic POLST approach, as explained in a Journal of Palliative Medicine article by Diane E. Meier, M.D. and health care journalist Larry Beresford published earlier this year, is to provide “actionable information on how to honor the wishes of a patient with a life-threatening condition” on a variety of issues. It goes farther than an Advance Directive (though if there’s a discrepancy, the Advance Directive takes precedence) and it differs from an out-of-hospital DNR (Do Not Resusitate) form because it lets you choose treatment.

I asked Henke if the patient/doctor conversation which is necessary in order for this extraordinarily useful document to be completed is covered by most insurance companies. She says that to her knowledge there is no specific code for such a conversation, although she understands there are other codes under which physicians can bill. Let’s hope Betsy McCaughey and Sarah Palin don’t find out. Or Chuck Grassley.

Though I am only terminal just now in the same sense that all of us mortals are, I talked about the POLST form with my Kaiser primary care physician just to be sure we remain on the same page. Wouldn’t it be nice if everyone had that same opportunity.

General interest/Health/Money/Politics & Causes/USA
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Pelosi Reaffirms Public Option, Insurance Reform; Healthcare "A Moral Imperative"

by Fran Johns

House Speaker Nancy Pelosi, addressing a Chamber of Commerce-sponsored Health Summit in San Francisco this morning about Obama’s health reform, stressed elements of the three House bills that might seem palatable to her audience: cost containment, IT design and integration with existing systems to create universal access to care. But she did not back down on a few other consistent statements such as the assertion that no bill will pass the House without a public option.

“We will invest in medical research and technology,” Pelosi said; and will incorporate elements such as electronic medical records for individuals to speed care.

It was clear there were mixed levels of support for reform in her audience. California Pacific Medical Center CEO Warren Browner MD, MPH drew muted chuckles and no boos with a throw-away comment that President Obama had “spent more time on choosing a dog” than on crafting a health policy. CPMC, a Sutter Health Affiliate, was presenting sponsor of the event.

Speaker Pelosi, though, hammered away at the primary intentions of reform: “improve quality, expand coverage and contain costs” while providing universal access to quality healthcare. “We will,” she said, focus on “quality, not quantity; wellness of the person not utilization (of facilities and technologies); value, not volume; and a commitment to prevention and wellness.”

San Francisco Mayor Gavin Newsom addressed the gathering earlier, touting the success of his “Healthy San Francisco” universal coverage program now in its second year. An independent Kaiser Family Foundation poll recently showed Healthy San Francisco to have a 94% approval record, prompting City/County Department of Public Health Director Mitch Katz, MD to ask when any program of any sort had ever gotten a 94% approval record. Citing the need for protection of such elements as in-home services in an aging population, Newsom said the program’s success was attributable largely to partnerships with local hospitals, clinics and medical facilities (CPMC is one), specifically singling out Kaiser Permanente, which signed on in July. The program does not offer a national model, Newsom said, but has many elements a national plan could adopt. Healthy San Francisco includes things that might not get into a national bill but are favorites with wellness proponents: community organic gardens, city-funded salad bars in schools and an ad featuring a soda-equipped young boy admitting to “a drinking problem.” Another key to the program’s success, Newsom said, is its ultra-simple one-page enrollment form.

Pelosi insisted that the final bill will include “insurance reform: no refusal based on pre-existing conditions, no co-pay for prevention, no cut-offs.”

And the major themes were reiterated: “As President Obama has said, universal healthcare is a moral imperative,” she said; “we are the only country in the developed world without it. I say to those who would have us do a little bit, and another little bit, and another little bit — Lyndon Johnson settled for half a loaf; this is the other half of the loaf.”

General interest
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What to do about Mom?

by Fran Johns

My friend Joan is distressed about her mother.   Joan – that’s an alias, we both value her privacy – lives quite near her parents, visits regularly, helps out with finances, health issues and everyday needs. They are in their late eighties. Other siblings live in other states. Until recently everything was fine; now the parents are in separate areas of their assisted living residence, Joan’s mother is in frequent despair and need. What’s a daughter to do?

This story is being repeated thousands of times every day across the country. Only this story has a peculiar twist: Joan’s parents did everything right. They lived frugally, planned ahead, raised their children to be successful and independent, moved early into a retirement community which offers care through illnesses minor and terminal. With Joan’s help they kept their affairs in order, including updated advance directives. (You don’t have your advance directives done? Horrors. Let me know and I will be at your door, cyberspacially speaking, to walk you through them immediately.) Joan’s parents were among early advocates for advance planning and end-of-life choice.

Joan comments: “Frankly, Mother is tired of being alive.  She’s not depressed, just ‘finished’, especially as she sees these slow declines in her quality of life as a steady and inevitable progression.  Her greatest desire would be to have a massive stroke and not survive.  But then her greatest nightmare would be to have a stroke and live . . . Even with the best advanced directives reflecting her choices, that’s a fine line to navigate.”

The moral of this story is that no amount of planning and preparation can guarantee the kinds of last months and years we might want. My own mother died peacefully at home, followed 20 years later by my father, same story. But that was in 1967 and 1987, in the small town of Ashland, Virginia where they had lived since 1939. The town looked after them; their out-of-state daughters merely visited and counted their blessings. Towns and neighborhoods like Ashland are in diminishing supply.

But all is not gloom and doom; this writer is constitutionally unable to write doom and gloom. Joan is at least clear about her parents’ wishes, and her parents have good care plus all allowable precautions: DNR orders, POLST forms, understandings with their medical professionals. Most of these are possible for today’s Boomers and their Beyonder parents; if you can’t find them I’ll happily tell you how. Joan’s parents are also in housing of their choice. And those choices are many: co-housing, retirement communities, assisted living facilities, many of them available to middle and low income Americans. Anyone over 50 who thinks he or she should postpone considering all of these issues, documents and choices until next year is delusional. Essays re housing choices have appeared in earlier Boomers and Beyond posts; others will follow. The secondary moral of this story is that without planning, late years can quickly turn into hell for elderly parents and adult children alike.

What we don’t have, of course, is health care such as Joan’s parents still enjoy for others who need it. The thing is, we can.

General interest/Health/Money/Politics & Causes/USA
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Healthcare: Sorting Fact from Fiction

by Fran Johns

House legislation on health reform is a win-some-lose-some proposition for those over 65. Especially, as outlined in The New York Times yesterday, when it comes to Medicare drug benefits.

Medicare beneficiaries would often have to pay higher premiums for prescription drug coverage, but many would see their total drug spending decline, so they would save money as a result of health legislation moving through the House, the Congressional Budget Office said in a recent report.

Premiums for drug coverage would rise an average of 5 percent in 2011, beyond the level expected under current law, and the increase would grow to 20 percent in 2019, the budget office said.

“However,” it said, “beneficiaries’ spending on prescription drugs apart from those premiums would fall, on average, as would their overall prescription drug spending (including both premiums and cost-sharing).”

The Congressional Budget Office report set off an immediate battle between Republicans and Democrats, each side eager to convince seniors — those vocal voters — that the other was representing the devil incarnate. Republicans swear the House bill will threaten Medicare beneficiaries in order to cover the uninsured, Democrats say the bill will help them by eliminating a gap in Medicare drug coverage.

On this particular segment of the impossibly complex bill, maybe seniors would do well to listen to their own purported champion:

Nancy LeaMond, an executive vice president of AARP, the lobby for older Americans, welcomed the report as evidence that “health care reform will lower drug spending.”

“Opponents of reform may use today’s projections to try to stall reform,” Ms. LeaMond said, “but we hope they will look at all the facts before jumping to a false conclusion.”

And there, some would suggest, is the problem. The facts have been virtually obscured by misstatements, misrepresentations and outright lies. Death panels? A lie that served its scary purpose. Rationing? It’s already here, folks; it’s done by insurance companies that deny coverage in sometimes arbitrary ways. Socialized medicine? Hello? Does anyone over 65 remember those screams before Medicare was signed into law in ’65? When half the population over 65 had no insurance coverage at all?

Set aside the fact that providing healthcare for all is simply the right thing to do. Millions of American seniors (whether you begin that definition at 65, 60 or — to their horror as it sometimes happens — 55) were motivated to support President Obama by not only their hearts but also their brains. If those brains can be called into play to sort fact from fear-mongering, we may yet get the health reform common decency requires of this otherwise civilized nation.

Health Bill Would Cut Drug Spending for Many on Medicare, Budget Office Says – NYTimes.com

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General interest/Health/Money/Politics & Causes/USA
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More on Health Care: Where the Costs Are

by Fran Johns

A few interesting factoids were dropped into the health reform debate by New York Times writer Amanda Cox Tuesday:

In 2006, health care expenses among half the United States population totaled less than $800 per individual, according to the federal Agency for Healthcare Research and Quality.

For openers, that seems entirely reasonable. Would that we could actually care for the citizenry at $800 a pop. Keep reading.

But the expenditures were not uniformly distributed throughout the overall population. Spending was far higher among the elderly, the obese and people who identified themselves as unhealthy. Median spending in those groups totaled $2,300 per individual. Although these patients represent just one-third of the population, they accounted for almost 60 percent of health care spending.

I hate to stomp this nearly dead — oops, bad metaphor — horse even further into its grave, but a lot of us, given the chance to talk to our doctors about aggressive, invasive, often futile end-of-life treatments that are going to make our ends horrific might choose to go home and spend our remaining time with palliative care, at peace. A nifty way to cut that $2,300 back down to $800. But Senator Grassley and others think we should now allow those conversations.

The truth may be too obscured by the cleverly promoted lies, but the issue is about choice. Compassion. Comfort. Peace. Sanity. If anyone could get this truth across to seniors, that one critical segment of reform might still survive. And personally, I’d like to have the option of saving the rest of you taxpayers my $1,500.

via Making Sense of the Health Care Debate – Prescriptions Blog – NYTimes.com.

General interest/Health/Money/Politics & Causes/USA
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Health Policy: Is Altruism Dead?

by Fran Johns

Recently in this space the me-first word was brought up. (It does not abbreviate well.) Might as well say it out loud: health reform could surely be sunk by the Me-Firsters, those who would put personal desires above the greater good, whether those desires are for better pharmaceutical or insurance industry bottom lines or for some corner of personal coverage, senior or otherwise, that might be sacrificed in the future.

I am not above having those desires. My husband and I actually have a tiny bit of stock in a drug company thanks to some mergers and buyouts I do not pretend to understand (I also don’t mess with the family stock portfolio) and thus a decline could cost household income we can ill afford. Plus, I would hate having the excellent care I get from Kaiser (thank you, Medicare) curtailed and would be seriously bummed if suddenly stuck with paying 100% of my post-cancer meds. But if that, or something equally draconian, is what it will take to get health coverage for my currently-uninsured friends, I would like to go on record as supporting whatever we must do to get access for all. This is not noble, just minimally humane.

There are noble people out there, however. They sign up for Teach for America, they volunteer in nursing homes and day care centers and hospice programs, put in long hours at food banks or take to the streets in other, similarly un-chic endeavors.

Re the current health reform brouhaha, there are also noble people, or at the very least altruistic people, all over the country; you just don’t hear a lot about them. On August 19, for example, President Obama urged supporters of health reform to “speak facts and truth” in what he said was a “contest between hope and fear,” and tried once again to refute some of the misrepresentations still widely circulating. His comments were themselves fairly widely circulated. But unless you happened to run across them in this space you would not have known they were made to 140,000 members of faith communities and/or supporters of community-organizing nonprofits. The people of Sojourners, Faith in Action, PICO and other groups that put together the 40 Days for Health Reform conference call are not in it for personal gain; they happen to believe everyone in this country should have access to health care. The next day, Nancy Pelosi held a press conference reiterating her determination to keep a public option in the final health bill. But again, unless you happened to see it here you would not have known the event was sponsored by the San Francisco Interfaith Council with a lot of help from its friends in the San Francisco Organizing Project.

When the religious right goes on a tear against abortion or end-of-life choice (or for that matter, when the religious left goes head-to-head with its ideologically-opposed brothers and sisters) it makes news. When community organizers stage high-profile protests, the same thing happens. What does not make news is the enormous effort made by people of good will just to promote the common good — most recently, health reform.

Some opponents of Obama and his reform bills even have an altruistic bone or two. The reportedly calm, if badly misinformed, Bob Collier, featured in a front page New York Times article August 25, allowed that “we’ve got to do something about those people who can’t get insurance.” He qualified that later: “There has to be a safety net there. But I don’t want that safety net to catch too many people.” Somehow, Mr. Collier wants to separate out the “truly needy” from the “lazy and irresponsible people who play the system” and wouldn’t we all. The Times said that Mr. Collier gets his information from Fox News, Rush Limbaugh and Matt Drudge, none of whom I see as particularly altruistic. I would surely welcome him to True/Slant.

But the people cited above, people in faith communities (including many I disagree with and some I can’t pronounce), progressive nonprofits, community organizing groups and others just roaming the streets being kind, these people seek access to health care for everyone without worrying about who deserves it and who does not. A great many of them worked hard to put Obama in office, and are now working hard for health reform for no reason other than it is the right thing to do for someone else. Might be unrealistic but they keep at it.

My money is still on those people.

General interest/Health/Money/Politics & Causes/USA
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Fear-Based Health Policy

by Fran Johns

Today’s New York Times features a number of stories about the proposed health reform bills, with one interesting thread: fear. Fear of “rationing,” fear of excessive costs, fear of the unknown, fear of the future. Take just the first, for example –

“Rationing.” It is what many people say they fear most from an overhaul of the health care system — the prospect of the federal government’s limiting the medical care they can receive.

Even some people who now have private health insurance through their employers have expressed this concern in opinion polls and public forums. They say they worry that the enormous price tag for providing care to tens of millions of additional Americans will eventually force everyone else to make do with less.

Of course it’s not a reasoned fear; rationing ‘s not going to happen any time soon. But somewhat like the tossing out of the utterly false “death panel” phrase, the R-word works to solidify the base for those who want no reform at all. And for some who simply want Obama to fail.

Aren’t the stakes a little too high?

Policy Experts Call Fear of Medical Rationing Unfounded – NYTimes.com

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General interest/Health
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Food, Gluten & Lifestyle Changes

by Fran Johns

I have pretty much done it all, gustatorily or libationally speaking: alcoholism, teenage fad diets (well, a long time ago, but trust me, they are still the same), brief descents into the pit of fast food, and now — Celiac Disease. Celiac Disease, forheavenssakes. It’s genetic. Where has it been all these years? And who, suddenly, are all these other CD people? If you aren’t one, you probably know one.

Dietary seasons, I have come to believe, are like life cycles, the ebbs and flows of some immutable tide built into our systems. As a kid, I didn’t like oysters, an incredible stupidity when my cousins lived a short drive away on the Chesapeake Bay. Bush (the grown-up one) banned broccoli from the White House, although it is surely the side dish to oyster dinners at the tables of the goddesses; perhaps he has now gained understanding. My children, I am sorrowful to admit, grew up on Hamburger Helper and Chuck Wagon Casserole through cycles of their mother’s chaos. And here they are, fitness buffs and gourmet cooks with healthy families, looking fondly back on their culinary childhoods.

I have now entered the Celiac Age. This affliction does not necessarily correspond with the Golden Years, one of the least appealing and often inaccurate descriptives of aging. Celiac Disease is not even a respecter of age. A colleague of mine has a teenage daughter who was so severely celiac as an infant they thought they might lose her before the diagnosis was made. She now sings with a chorus that travels in Europe periodically, so Stewart can translate the diet into seven languages if you need him to.

Recent estimates are that as many as 1 in 100 Americans have CD, with a large percentage of them as yet undiagnosed. I won’t bore you with the symptoms, some of which are quite gastrointestinal and unpleasant; mine were just sudden weight loss and anemia. But what they all translate into is you can’t eat gluten. Gluten is found in wheat, barley, rye and oats and right away you can see donuts are out. CD is an autoimmune disease, so they’re out forever. On the other hand, we should all sign up for something that can be cured through the simple act of eliminating one thing from one’s diet. And if you consider what CD people can eat: meat, fish, vegetables, fruit, ice cream, chocolate candy, meringue cookies, frozen coffee drinks…

Still, we CD people have our moments of pitifulness. My latest was in a posh restaurant up the street at which I was told that everything on the dessert menu contained gluten, because they put gluten even into their ice cream so they can make fancy little plops. They have already received my e-mail about that 1 in 100 business. Actually, being asymptomatic now that I’m taking all these vitamins, I could eat that loaf of bread (it belongs to my husband) over there and never know the difference. But Dr. Yeo would know. Dr. Yeo watches the lab test results and they do not lie. And in truth, I need my bones, which don’t get their calcium if I cheat.

We try not to complain. Still, having given up pies, cakes, cookies, brownies, donuts and sticky buns I did manage to regain the lost weight and another uninvited 4 pounds. There is no justice. Tomorrow: a view of risk/benefit wine drinking.

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