Nuggets of Truth In ‘Death Panel’ Rhetoric (Palin Derangement Syndrome yet he admits she's right!)

CQ Politics ^ | September 4, 2009 | John Edgell

[2ndDivisionVet]

When former Alaska Gov. Sarah Palin introduced “death panels” to the health care overhaul debate vernacular via Facebook in early August, she showed herself to be a brilliant idiot.

Technically, Palin’s claim of a panel of “downright evil” government bureaucrats rationing health care based on Americans’ “level of productivity” is obviously idiotic. There is not, and never will be, some mythical jack-booted panel of government pinheads, rubber stamps in hand, deciding who shall live and who shall die. As such, Palin was deservedly roasted.

Tactically, however, Palin’s move was pure brilliance: in but a few keystrokes she synthesized the underlying suspicion at least half of Americans have about a government role in health care delivery and created a visual metaphor from which the Obama White House and congressional Democrats still haven’t fully recovered.

So would it surprise you that Palin has a legitimate point? Well, sort of.

There actually is a government-appointed panel, named MedPac, which is made up of health care experts — those pesky pinheads — who analyze and make policy decisions, including policies about death. MedPac oversees and evaluates Medicare’s costs, physician payments and quality controls. Its decisions affect health care coverage for 40 million American elderly and the medical institutions involved in end-of-life care — in this case, hospice care.

In other words, there is a government panel which makes decisions that affect when (but not how) a hospice can “pull the plug on Grandma.” So does Iowa Republican Sen. Charles E. Grassley have legitimate point too? Well, sort of.

It depends on whether you believe for-profit hospices should be tacitly encouraged to keep patients under their care for extended periods of time in order to bilk Medicare for more days of service to pad their profit margins, and at largely taxpayer expense.

While Palin’s baby son Trig, who has Down syndrome, would never be denied needed medical care and left to die by some mythical bogus death panel, there actually is some truth that changes in Medicare’s reimbursement methods for hospice care will affect how and for how long millions of senior citizens spend their final days.

First, some background on Medicare’s hospice benefit, which began in 1983 primarily for the near-death elderly, mostly cancer patients, through nonprofit hospice facilities affiliated with religious and community organizations. By 2005, hospices treated 1.2 million patients and one-third of Americans who died did so at a hospice facility. Hospice admissions continue to increase at roughly 10 percent per year.

Overall, Medicare hospice spending more than tripled between 2000 and 2007, to more than $10 billion. Total hospice care will cost roughly $46 billion by 2030.

The future in hospice is all about how to make a buck — make that big bucks — and increasingly at the expense of Medicare patients and taxpayers. In 1990, for-profit hospice treated 9 percent of total hospice patients; today, it’s now 35 percent of total patients. Nonprofit hospices still treat 56 percent of the total number of patients, but that figure is trending steadily downward.

What began with largely charity-based Medicare hospice providers has in the past decade or so morphed into a multibillion-dollar, profit-driven corporate enterprise. Between 1994 and 2004, Medicare saw a 400 percent growth in the total number of for-profit hospice facilities, which is six times the rate of increase of Medicare-participating non-profit hospices. In the past decade, nearly 1,000 new for-profit hospices joined Medicare.

Hospice is now a huge profit center. The Journal of Palliative Medicine cited a 2005 study that large publicly owned hospice chains generate profit margins nine times higher than those of large nonprofits and three times higher than privately owned for-profit hospices of similar size. The biggest for-profit, publicly-owned hospice is VITAS, which treats more than 11,000 patients in 16 states. Other large chains are the publicly owned Odyssey Healthcare and Vista care, and the private Heartland Hospice, a division of HCR Manor Care, which in 2007 was bought by the Carlyle Group, the mega-investment firm, for $6.3 billion.

In June 2008, MedPac reported that length of stay in a for-profit hospice is roughly 45 percent longer than the length of stay in a nonprofit facility. Of course hospices with longer lengths of stay are more profitable.

So, inversely, and cynically speaking, does a typical nonprofit hospice affiliated with the Catholic Church ruthlessly “pull the plug on Grandma” much sooner than necessary, at least as compared to the kinder, gentler for-profit Heartland Hospice facility?

Longer stays at for-profit hospices doesn’t assure better care either. A 2004 study looked at 2,080 patients in 422 hospices and determined for-profit hospices provided terminally ill patients in need of end-of-life care a “full range of services only half the time compared with patients treated by nonprofit hospice organizations.” That’s because for-profit hospices lower costs by cutting services, namely “non-core” services such as prescriptions and labor-intensive personal care such as bathing. Moreover, families of patients at a for-profit hospice received counseling services, including bereavement counseling, only 45% as often as those at a nonprofit hospice.

In other words, Medicare hospice patients stay significantly longer at for-profit hospices than at nonprofit hospices, yet receive far less personal attention and spiritual counseling. Medicare’s existing reimbursement system contains incentives that make very long stays in a for-profit hospice hugely profitable, especially if labor-intensive patient care is purposefully denied.

Given this evidence, in January 2009, MedPac recommended that beginning in 2013, Medicare alter its current payment system for hospice care providers serving terminally ill patients, the first such method change since 1983. Instead of its current predictable flat-rate per diem payment rate to hospices caring for the terminally ill, Medicare would pay relatively higher payments per day at the beginning of the episode, and relatively lower payments per day as the length of the episode increases — a fairly radical and provocative departure from current policy.

At a certain point though, any elderly patient could cost more to keep alive than Medicare’s daily reimbursement payment rate. Again — cynically speaking — the longer a Medicare patient’s hospice stay, the less incentive a hospice has to keep a near-death patient alive. Would Grandma’s plug be pulled then to protect a profit margin?

If so, to quote Palin, sort of, “such a system is downright evil.”

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John Edgell is a former Democratic congressional staffer.

[RobbyS]

Sarah is a natural orator. That means she know how to words that have real punch, that people remember. As opposed to someone like McCain who just drones on and on.

[Sun]

“in this case, hospice care.”

Terri Schiavo was murdered in a hospice, so I don’t ever want my loved ones, or myself, to go to one.

I know there are some prolife hospices, but how does one know which ones are prolife.

[Ann Archy]

There HAS to be Death Panels sometime to keep the cost down and next there will be BIRTH PANELS to keep the amount of children being born that we can’t afford to take care of. LOOK OUT, AMERICA!

[new cruelty]

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