The section of the bill re: elderly end-of-life consults

[dave338]

SEC. 1233. ADVANCE CARE PLANNING CONSULTATION.
(a) MEDICARE.—
(1) IN GENERAL.—Section 1861 of the Social
Security Act (42 U.S.C. 1395x) is amended—
(A) in subsection (s)(2)—
(i) by striking ‘‘and’’ at the end of subparagraph (DD);
(ii) by adding ‘‘and’’ at the end of subparagraph (EE); and
(iii) by adding at the end the following new subparagraph:
‘‘(FF) advance care planning consultation (as defined in subsection (hhh)(1));’’; and

(B) by adding at the end the following new subsection:
Advance Care Planning Consultation
‘(hhh)(1) Subject to paragraphs (3) and (4), the term ‘advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.

(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.

(C) An explanation by the practitioner of the role and responsibilities of a health care proxy.

(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded
through the Older Americans Act of 1965).

(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include—
(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes;
(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and
(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy).

(ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State—
(I) in which all legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and
(II) that has in effect a program for orders for life sustaining treatment described in clause (iii).

(iii) A program for orders for life sustaining treatment for a States described in this clause is a program that—
(I) ensures such orders are standardized and uniquely identifiable throughout the State;
(II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional’s authority under State law) may sign orders for life sustaining treatment;
(III) provides training for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and
(IV) is guided by a coalition of stakeholders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors,
agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association.

(2) A practitioner described in this paragraph is—
(A) a physician (as defined in subsection (r)(1)); and
(B) a nurse practitioner or physician’s assistant who has the authority under State law to sign orders for life sustaining treatments.

(3)(A) An initial preventive physical examination under subsection (WW), including any related discussion during such examination, shall not be considered an advance care planning consultation for purposes of applying
the 5-year limitation under paragraph (1).

(B) An advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.

(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order.

(5)(A) For purposes of this section, the term ‘order regarding life sustaining treatment’ means, with respect to an individual, an actionable medical order relating to the treatment of that individual that—
(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who
is acting within the scope of the professional’s authority under State law in signing such an order, including a nurse practitioner or physician assistant)
and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care;
(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;
(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and
(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.

(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items—
(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems;
(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting;
(iii) the use of antibiotics; and
(iv) the use of artificially administered nutrition and hydration.’’


(2) PAYMENT.—Section 1848(j)(3) of such Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting
(2)(FF), after (2)(EE).

(3) FREQUENCY LIMITATION.—Section 1862(a) 5 of such Act (42 U.S.C. 1395y(a)) is amended—
(A) in paragraph (1)—
(i) in subparagraph (N), by striking ‘‘and’’ at the end;
(ii) in subparagraph (O) by striking the semicolon at the end and inserting ‘‘,and’’; and
(iii) by adding at the end the following new subparagraph:
(P) in the case of advance care planning consultations (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section;’’;
and
(B) in paragraph (7), by striking ‘‘or (K)’’ and inserting ‘‘(K), or (P)’’.

[dave338]

Sorry for the long text, but I want to make some points-

1) the first BLUE section indicates that all this information is amending section 1861 of the Medicare Act, which is a list of DEFINITIONS of covered services.

2) the second BLUE section indicates that the consult will only be covered if there hasn't been one in the last 5 years, and references paragraph 3, which says such consults MAY be covered if there's a significant deterioration in the patient's health.

3) The final blue section is where you would see the word "mandated" - instead, it says "covered" when talking about the frequency. Specifically, it amends section 1862 of the medicare act to say that these consults will NOT be paid for if performed more than once every 5 years (or as mentioned in 2) above).

I want anyone to tell me where this indicates compulsion, where it indicates WHO will be compelled, where it indicates WHAT has to be wrong with someone to be compelled, or ANY OTHER EVIDENCE that this is anything but a definition of a service that may be performed by a physician.

[dave338]

For further reference, here are sections 1861 and 1862, which are modified by the above bill.

1861: http://www.ssa.gov/OP_Home/ssact/title18/1861.htm
1862: http://www.ssa.gov/OP_Home/ssact/title18/1862.htm

[Dougles]

I understand the need to disprove Mike, but I hope you realize this is all just smoke and Mirrors. The right is throughing it out their to scare people and the left keeps it in the public eye to keep the serious quesitons out of the media, like how will this actually save anyone any money!

[dave338]

And I appreciate your concern about money. My concern is blowing through the smokescreens. If a person's concern is that it will cost us money, or bankrupt the country, then FINE. Say that, with backup.

Making things up to try to scare the elderly into thinking "ObamaCare" will kill them when they're 65 or that people will lose the choice of private healthcare if they lose their current coverage is NOT a valid discussion method. Claiming that doctors will move out of the country to practice because they won't be able to accept cash payments is UNTRUE and inflammatory.

I'm not debating the merits of the entire bill, because neither are mike or any of the others who make this stuff up. They're trying to scare people, pure and simple.

[therising]

Where's Mike?

[dave338]

He's still posting in the other thread claiming he's right. Even though the link he posted to prove himself right actually goes to great lengths to prove him wrong.

[ILOVEDNY]

Well, well, well.
Seems the Senate agrees with the majority of Americans.
End of life "counseling" dropped.
http://briefingroom.thehill.com/2009...ife-provision/

[dave338]

Agreed with, or caved into? The fact remains that nothing in the bill MANDATED anything.

[ILOVEDNY]

Agreed with, or caved into? The fact remains that nothing in the bill MANDATED anything.

I hardly think listening to the public is caving in.
And your interpretation of the house bill was just wrong.
But I know you'll never man up to that.

[dave338]

I hardly think listening to the public is caving in.
And your interpretation of the house bill was just wrong.
But I know you'll never man up to that.

Fine - you show me your interpretation, with specific reference to the bill, that supports the mandatory nature of the consults and I'll "man up" to it. Mike refused to do anything but paste in other people's opinions, with NO references to the actual bill, and that's not how someone is going to convince me that I'm wrong.

I'm sincere in saying that I want to see how you can interpret the information I posted above - straight from the bill - to mean that the consults are mandatory.

[therising]

Well, well, well.
Seems the Senate agrees with the majority of Americans.
End of life "counseling" dropped.
http://briefingroom.thehill.com/2009...ife-provision/

When Obama doesnt negotiate = he's a bully
When Obama does negotiate = it's "well, well, well.."

[Surfing USA]

Fine - you show me your interpretation.....

That's my biggest problem with this bill. Nothing should have to be "interpreted." If it were clear and precise, there would be no arguments about what it actually says.

You have to wonder if they worded it, (the way they did,) so they can interpret it, (any way they see fit,) AFTER it's passed.

[dave338]

That's my biggest problem with this bill. Nothing should have to be "interpreted." If it were clear and precise, there would be no arguments about what it actually says.

You have to wonder if they worded it, (the way they did,) so they can interpret it, (any way they see fit,) AFTER it's passed.

Surfin' - I actually feel that there's no room for interpretation on this specific issue. Elsewhere there probably is. I see this as a straightforward case of

1) defining what such a consult is, and
2) defining when Medicare will pay for it.

I asked for ILOVEDNY's interpretation because I honestly can't imagine reading the words and getting anything else out of it.

[ILOVEDNY]

The bill has been marked up and passed out its last House Committee.
And guess what?
Despite the controversy, the bill was not amended to make it clear that the counseling was voluntary!
In fact, the language was barely changed at all.

Now, I suppose that an argument could be made because the bill does not explicitly mandate counseling.
However, if that is the case, what would be the harm in making it clear?

If I wanted to put this controversy to rest, if I wanted to ensure that eldsters didn’t worry that they would be pressured to refuse treatment.
If I wanted to direct the bureaucrats who will create the regulations implementing the general mandate of the bill.
I would quickly make it abundantly clear that the end of life counseling was voluntary.
As is done in a different section of the bill that would pay for home visit counseling for families with young children.


But that wasn’t done, despite all the controversy. So the question is, “Why, wasn’t it done?”