With respect to the current amendment process, the National Right to Life Committee urges members of the Senate Finance Committee:
1. TO SUPPORT Amendments 125/137 to eliminate the 5% penalty for Medicare physicians in the top 10% of spending.
2. TO SUPPORT Amendment 152 to allow senior citizens to opt out of Medicare.
3. TO OPPOSE Amendments 207, 208, and 210, relating to advance care planning, in their current form.
The National Right to Life Committee expects to take positions on additional amendments.
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A brief statement of our reasons for the positions summarized above follows:
1. TO SUPPORT Amendments 125/137 to eliminate the 5% penalty for Medicare physicians in the top 10% of spending.
The provision penalizing doctors establishes that for at least five years, Medicare physicians who authorize treatments for their patients that wind up in the top 10% of per capita cost for a year will lose 5% of their total Medicare reimbursements for that year [see footnote 1 at bottom of release].
This means that all doctors treating older people will constantly be driven to try to order the least expensive tests and treatments for fear that they will be caught in that top 10%. It is noteworthy that this feature operates independently of any considerations of quality, efficiency, or waste - if you authorize enough treatment for your patients, however necessary and appropriate it may be, you are in danger of being one of the 1 in 10 doctors who will be penalized each year. Moreover, it creates a moving target - by definition, there will ALWAYS be a top 10%, no matter how far down the total amount of money spent on Medicare is driven.
It's like a game of musical chairs, in which there is always one chair less than the number of players – so no matter how fast the contestants run, someone will always be the loser when the music stops.
The incentive this creates is purely cost-driven, without any balancing of benefit. It will create a constant sense of uncertainty in doctors, since none can know in advance precisely what the cutoff for a given year will be - resulting in still more pressure to limit treatment and diagnostic tests to the bare minimum.
2. TO SUPPORT Amendment 152 to allow senior citizens to opt out of Medicare.
In order to pay for subsidies for insurance to the uninsured, the Chairman’s Mark includes significant reductions in payments that would otherwise be made under Medicare, including the authority for the Medicare Commission to impose limits on the rate of growth below the rate of medical inflation. This will make it increasingly difficult for senior citizens to obtain medical treatment under Medicare. They ought, at the least, to have the legal option of opting out of Medicare. Under this amendment, as with those parents who send their children to private schools, those opting out of Medicare would not be relieved of having had to pay into Medicare; they would just be able to use their own funds to obtain health insurance less constrained than that under Medicare.
3. TO OPPOSE Amendments 207, 208, and 210, relating to advance care planning, in their current form. These amendments would provide for governmental payment for advance care planning and various other ways of promoting advance directives. National Right to Life strongly encourages the execution of a pro-life advance directive, the Will to Live. However, the pro-life fear is that efforts to push patients and prospective patients to prepare advance directives may in practice become a means of persuading or pressuring them to agree to less treatment as a means of saving money.
Advocates of such measures frequently cite the cost savings if, as they expect, this promotion results in more directives rejecting life-saving treatment. Efforts to push patients and older people to prepare advance directives may in practice become a means of persuading or pressuring them to agree to less treatment as a means of saving money.
There have been several recent studies showing how advance directives and end of life conversations generally yield cost savings. A 2009 Archives of Internal Medicine study concluded, “Patient-physician discussions about [end of life] wishes are associated with lower rates of intensive interventions.”The mean cost of care was 35.7% less for patients who reported having end-of-life discussions compared with for patients who did not in their final week of life. “We refer to the end-of-life discussion as the multimillion-dollar conversation because it is associated with shifting costs away from expensive . . . care like being on a ventilator in an ICU, to less costly comfort care…,” noted Dana-Farber's Holly Prigerson PhD. A recent JAMA study reaches a similar conclusion that, "On the other hand, patients who reported having end-of-life discussions received less aggressive medical care and were more likely to receive hospice services for more than a week."
With this background, significant safeguards would need to be incorporated in any program for advance care planning – safeguards not fully present in the relevant amendments – in order for the promotion programs and consultation element to be truly protective of the values and intent of senior citizens, and to ensure they are not pressured into rejecting treatment against their true wishes. Therefore the National Right to Life Committee urges rejection of the amendments in their present form.
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