AHRQ Spending $300 million on Comparative Effectiveness Research

The Agency for Healthcare Research and Quality (AHRQ) will use $300 million allocated for comparative effectiveness research under the American Recovery & Reinvestment Act (ARRA, Pub. L. No. 111-5) to expand and broaden pre-existing comparative effectiveness research activities, according to a July 30th proposal detailing the agency's spending plans.

ARRA appropriated a total $1.1 billion for comparative effectiveness research (CER), of which $300 million is for the AHRQ to spend in fiscal years 2009 and 2010. AHRQ said it will use the ARRA funds “to conduct and support research that will result in current, unbiased, evidence on health care interventions that will aid patients, health care providers, and policymakers in decision making.”

End-of-Life Treatment Consultations IMPROVE Care

Compassion & Choices collects peer-reviewed, published studies establishing that end-of-life consultations improve care. Among other points made in the linked articles:

• End-of-life discussions decrease suffering and distress for patients and loved ones
• Hospice patients live longer
• Inability to participate in treatment decisions can cause patients uncertainty and distress
• 87% of patients say they “want as much information as possible”
• Patients want doctors to communicate with them about their treatment options

Rationing - Is It Necessary?

We use the word "ration" when we have to conserve something; so you would be surprised to hear it used in conjunction with healthcare, something that we all believe is meant to be made available to those who really need it. But,

The problem with healthcare rationing is that it allows others besides the people who need healthcare to make decisions for them. While those who have the money are able to buy the kind of treatment they want with private insurance plans, the others who are on plans like Medicare and Medicaid are forced to rely on these plans for any form of healthcare. So if the plan does not allow them to seek a treatment that is controversial or not proved to be effective (like alternative medicine), then they cannot opt for that treatment, even though they want to do so.

This raises the question of the elderly – while new rationing measures call for counseling rather than prolonged care and treatment which is deemed unnecessary because it is only an expense that delays the inevitable, people are raising their voices in asking how the government is allowed to dictate who gets to be treated and who does not. Often, it’s not the doctors who have the autonomy to decide but the insurance companies. And this is where rationing goes terribly wrong – with money, not the individual, being the deciding factor, you can see why there is an outburst against rationing.

Healthcare rationing is important, as is the need to provide universal healthcare. But, the purpose of rationing should be for the following reasons:

• The cost of healthcare to the nation must come down
• Individuals must have access to basic healthcare
• It is in the best interests of those who really need healthcare but who cannot afford it on their own without help from the government
• It does not serve to fill the coffers of the insurance companies who only seek to profit from various healthcare plans.

If there is no rationing whatsoever, then costs are bound to soar and the national healthcare budget will take a beating that it cannot recover from. And if rationing is done on a broad scale, taking into consideration only the insurance companies, then healthcare itself will take a beating. We can only hope that Obama’s new healthcare rationing plan proves to be the success that he claims it will be, for the sake of our nation’s healthcare system which is in danger of collapsing under the burden of expense.

By-line: This guest article was written by Adrienne Carlson, who regularly writes on the topic of online phlebotomy certification. Adrienne welcomes your comments and questions at her email address: adrienne.carlson1@gmail.com

Nothing Wrong with End-of-Life "Persuasion"

Wesley Smith wrote yesterday that "[t]he Medicare “mandatory counseling” controversy in the Obamacare debate laid bare a realistic fear that compensated counseling under Medicare could easily become subtle (or not so subtle) persuasion to refuse treatment." He goes on to explain why that would be dangerous.

But there is nothing wrong with "persuasion." Tne Encyclopedia Brttannica defines "persuasion" as

the process by which a person’s attitudes or behaviour are, without duress, influenced by communications from other people. . . . The communication first is presented; the person pays attention to it and comprehends its contents (including the basic conclusion being urged and perhaps also the evidence offered in its support). . . . similarities between education and persuasion. They hold that persuasion closely resembles the teaching of new information through informative communication.

The history of physician-patient communication confirms the acceptability of persuasion. Physicians used to just paternalistically keep patients out of the decision making process. They later swerved to the other end of the continuum, abandoning patients to their autonomy. Carl Schneider and others have carefully reviewed the psychological and anthropological literature. Patients want guidance from their physicians. Thus, the dominant model today is a collaborative one. Physicians can and should share (and even defend) their opinion as to the best course of action, offering evidence and reasons (i.e. be persuasive).

Now, perhaps Wesley Smith is concerned about physician manipulation, coercion, or deception. I too fear these things. But there is no evidence that any of it would be expanded or acceletated by paying for advance care planning.

The Resurrectifier

Many Physicians Feel Like Sisyphus

In the Afterlife, Zeus and the other Gods condemned Sisyphus to push a heavy boulder up a high, steep hill. The rock kept rolling back down, and Sisyphus was compelled to push it back up, again and again, for all eternity. Today, many physicians play the role of Sisyphus. Is the fear of litigation today's Zeus "demanding" futility?

The "Kill Granny" Media Campaign

Healthcare providers, state governments, and numerous advocacy organizations (like AARP) have tried for years to increase the amount of advance care planning in the United States. Why? To protect and promote patient autonomy. To close the giant gap between the care that patients say they want and the care that they actually get.

There are many obstacles and hurdles to ACP. But pending health reform legislation would address at least one of these by reimbursing physicians for discussing end-of-life treatment alternatices with their patients. Section 1233 in H.R. 3200 is not even an informed consent law like California's statutorily-mandated "right-to-know" law (also enacted or considered in Arizona, Maryland, and others states). It does not require any particular treatment. It does not require any particular discussion. It leaves all of that to state law. It merely authorizes the provider to bill Medicare if she/he does ACP counseling.

Now, there is a new hurdle to ACP. A media campaign "has sparked fear among senior citizens that the health-care bill moving through Congress will lead to end-of-life 'rationing' and even 'euthanasia.'" (Washington Post) On right-leaning radio programs, religious e-mail lists and Internet blogs, Section 1233 has been described as "guiding you in how to die," "an ORDER from the Government to end your life," promoting "death care" and, in the words of antiabortion leader Randall Terry, an attempt to "kill Granny."

Now, there will be rationing. Granny's treatment choices in 2015 will be more limited than they were in 2005. But Section 1233 and ACP have nothing to do with that.