repealing health care reform and rescinding payment for end of life counseling

This last week brought a couple of disappointments.

1. The House of Representatives passed a bill to repeal the health care reform package: This was expected and "largely symbolic" since the senate will not approve it and the president will not sign it. I think that it is not largely symbolic, but rather largely strategic. It has the psychological effect of making people remain confused about exactly what health benefits they will have, on top of the confusion that already exists due to the complexity of the present bill. Because of confusion and insecurity about the provisions of the health care bill, hospitals and doctors are acting slowly to take advantage of the changes that are scheduled to occur, and so positive changes that would be more likely to make the primarily democrat backed plan look good to American voters will be less evident. As a physician, the stuttering pace of change is frustrating and discombobulating. 
2. Congress decided that they will not pay for counseling about end-of-life choices for patients with Medicare, despite the recommendation that this be done by the Center for Medicare Services. Speculation is that such payments would lead to more "death panel" rhetoric from Republicans. Payments for counseling on obesity and smoking cessation and healthy diet are now paid for as preventive services, but not discussions with patients about whether they would want to be on life support if their hearts or lungs would fail.  Responsible physicians do have these conversations with patients, but many are very uncomfortable doing this because they believe that it will be depressing and maybe that it will communicate to the patient the false impression that the doctor is expecting the person to die soon. Conversations about end of life care are difficult and emotionally taxing, much more so than discussions of smoking cessation, and really make a difference in how comfortable a person is in dying. They make the lives of family members better at a time when the pain of grief makes talk of details difficult. I personally will not change my practice with regard to learning about a person's end of life preferences because of the fact that I will not be paid for it. Many doctors, though, are hesitant to have such discussions, and this leads to a crisis mentality during a patient's final illness with associated emotional and monetary costs.

 These particular events are not earth shattering, and will eventually come to nothing, as we gradually re-form the health care reform bill to meet our needs, and as physicians gradually come to accept the fact that patients mostly want to be involved in decisions about the medical treatments they receive at the end of their lives. It is hard, though, to watch this wasting of effort and the conflict it produces as we take another step backward in the slow dance toward fixing our health care mess.