Washington Post reporter Alec MacGillis thinks that the city of La Crosse, Wis., is “a good place to die.” Maybe, maybe not, but La Crosse sure is a good place to die fast and save the hospital some money.
The headline to MacGillis’s story touts La Crosse as “the unwitting birthplace of the ‘death panel’ myth.’ That’s because one of the town’s hospitals, Gundersen Lutheran, aggressively pushes “end-of-life planning” onto its older patients–and also aggressively lobbied Congress to make sure that the health-care bill contained a provision allowing Medicare reiumbursement for the planning “conversations.”
The hospital began urging families to plan while people are healthy. For those who want help writing a directive, a physician will discuss the powers and limits of medicine and explain to family members what it means if they agree to serve as the “health-care agent.” They will also help people define the conditions under which they would no longer want treatment. Hammes said people often define this as “when I’ve reached a point where I don’t know who I am or who I’m with, and don’t have any hope of recovery.”
The “Hammes” is Bud Hammes, director of “medical humanities” at Gundersen.
“The [directive] itself doesn’t really matter very much — it’s the clearly expressed belief and shared understanding that it represents,” Hammes said. “The family members have to believe that what they do is not only legally right, but personally right. If Mom said, ‘Don’t do this or do do this,’ it’s much easier for them to say, ‘I’m doing a loving thing,’ and it’s a decision you can live with.”
According to MacGillis, some 90 percent of La Crosse’s older residents now have directives thanks to the hospital’s insistence. And perhaps not surprisingly, Gundersen saves a bundle of dough:
The reliance on directives has an impact on the type of care people receive: Gundersen patients spend 13.5 days on average in the hospital in their final two years of life, at an average cost of $18,000. That is in contrast with big-city hospitals such as the University of California at Los Angeles medical centers (31 days and $59,000), the University of Miami Hospital (39 days, $64,000) and New York University’s Langone Medical Center (54 days, $66,000).
But Gundersen staff members say those conversations take a lot of time — a good hour, plus follow-up talks to alter directives as medical situations evolve. And Medicare does not reimburse doctors for the time spent on such discussions.
So Gundersen won a big victory when the House “tucked” (MacGillis’s word) a reimbursement provision into its health care bill–a victory later quashed when Sarah Palin started talking about death panels, Senate Republicans insisted on dropping a similar provision from its own health bill, and the White House indicated it was willing to get rid of the provision, too. So it’s a dark day for Gundersen, MacGillis writes:
The hospital officials are even less hopeful about more ambitious terms they sought to add — changing Medicare payments for end-of-life care so that they are based not on the procedures a patient receives in the final months but on whether care complied with the person’s wishes.
Mickey Kaus (whose link brought the story to my attention) comments:
The obvious question MacGillis ducks: What if you write a directive that says you want aggressive and expensive death-delaying measures to be taken? “I’d like to die hooked up to machines.” Do the hospitals of LaCrosse just automatically follow your wishes and spend $100,000 in your final weeks, telling themselves that it’s a “shared understanding” and “a loving thing.” Or is … subtle pressure exerted to have a further “conversation”? …
There’s another issue that MacGillis ducks: conflict of interest. Physicians at Gunderson receive a flat salary instead of being paid by the procedure, which means that for every medical treatment foregone by a patient after a “conversation,” there’s less work for the doctor. That could be why, if you look at the first photo in the slide show that accompanies MacGillis’s story–a photo of three doctors contemplating an X-ray of a terminal patient’s heart–you’ll notice that one of the doctors is smiling.