• On The Record (with daily recap)

    • Milliman: The Strength of the Individual Mandate in the ACA

    Today in TIE: Austin on shared decision making and his appointment to CEPAC, Aaron points out that docs (and most other people) don’t understand screening statistics, while Don looks at surrogates carrying out medical decision making wishes (or not).

    DT

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  • When surrogates override wishes

    Alex Smith points out a fascinating paper and teaching video that recounts the story of two daughters who override the wishes of their 83 year old mother regarding life sustaining treatment. Alex summarizes the story this way:

    • An 83 year old woman with complex medical conditions becomes septic and is seen in the emergency department.
    • She has an advance directive that clearly states “Do Not Resuscitate, Do Not Intubate,” designating her oldest daughter as her surrogate decision maker.  She talked with both daughters about her wishes.
    • The doctors ask her daughters for permission to place her on a ventilator
    • The patient, very ill and turning grey, says “no-no-no” and wags her finger
    • The patient becomes unresponsive, and the daughters grant permission to intubate her and transfer her to the ICU

    Even more interesting than the paper, the daughters agreed to be videotaped discussing this case (“Twenty-two days and two blinks of an eye”), which eventually ended when they decided to have their mother de-intubated and she died. As both the paper and video show, this is a far more nuanced story than someone simply not following the wishes of another person at the end of life. Instead, it touches on many issues: communication, consent, leeway, who preferences/needs should be included in end of life decisions, and how to deal with differences within families on these very difficult choices. Further, your mother only dies once, so it is the health care system that needs to work on learning from difficult experiences and trying to make it more likely that bad ones are not repeated.

    I have shown the video to several people who had very divergent feelings after viewing it, so I pass it along without any more comment, except to say that these two daughters are very brave for allowing this story to be shared so publicly.

    DT

    Peter M. Abadir, Thomas E. Finucane, Matthew K. McNabney. When Doctors and Daughters Disagree: Twenty-two Days and Two Blinks of an Eye. J Am Geriatrics Society 2011;59(12):2337-30.

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  • On The Record (with daily recap)

    Today in TIE: Austin writes about why we insure the little stuff, Don reports on what students think about deficit reduction, while Aaron has more on it is hard to cut Medicaid.

    DT

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  • College students and deficit reduction

    Last week the students in the class I co-teach with David Schanzer (Gridlock: can our system address America’s big challenges?) completed an in-class exercise created by the Concord Coalition that lets people devise their own plan to reduce the federal budget deficit (or not) over the next 10 years. A brief report on what they (10 groups of about 4 each; mostly undergrads, with a few grad students) decided.

    • 9 of the 10 groups embraced policies that would reduce the federal deficit over the exercise baseline (which includes taxes greatly increasing on Jan. 1, 2013 and the implementation of the ~ $1.2 Trillion in spending cuts agreed to in the debt limit deal).
    • The spread of the difference between the groups was over $5 Trillion over 10 years (a $430 Billion increase in the deficit to a $4.7 Trillion decrease, over 10 years; half of the groups identified deficit reduction of over $3 Trillion, again as compared to the baseline noted above).
    • You can download the materials we used (and you can use with a class, etc.) here.
    • The students engaged in long discussion about investing more in some areas, while cutting in others.
    • Any such exercise necessarily simplifies the choices available, and this one boils it down to 40 choices about spending and taxation. The portion of the exercise that students were most frustrated with was the section on health care and Social Security. They wanted more nuance than was available in this section. For example, it offers the choice to repeal the ACA, or not. Likewise, they wanted more subtlety to address Social Security with a mix of benefit cuts and taxes.

    There are other models available for such an exercise, and I highly recommend the online budget simulation tool developed by the Committee for a Responsible Federal Budget. It provides a bit more nuance in some of these key areas than does the tool produced by Concord, but the materials from Concord were more suited to an in-class group discussion format. Tradeoffs! Both are excellent tools to get students (and anyone) thinking about the choices our nation faces.

    DT

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  • On The Record (with daily recap)

    Today in TIE: Austin on guideline-driven care and geographic variability and reading list, Don with more on the Goldilocks principle, this time in the mortgage realm, Aaron with two posts on why high deductible plans likely won’t save that much money (post 1, post 2) and a personal tale of his interaction with the health care system.

    On The Record wishes you a happy weekend.

    DT

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  • Mortgage standards and the housing market

    Suzy Khimm asks whether credit worthy Americans are having trouble getting a mortgage? A bit of a personal follow up to this long term care story, with some comments about the housing and mortgage markets in Durham, N.C.

    • Next week we are closing on and moving into a house that can accommodate my family (wife and 3 kids) and mother-in-law. We had some very specific criteria in terms of layout (needed mother in law suite/apartment) and no flexibility in terms of school district.
    • We identified 5 houses that fit our criteria; all of them were empty* and one was in foreclosure. I priced having a comparable new home built and it would have cost ~30-40% more than what we ended up paying for a ~ 10 year old house. Interestingly, the contractor that I talked with about building me a house told me he got his first straight custom build contract in 2 years last week (though he has had major amounts of renovation work the past 9 months).
    • We had a very good credit score, and were able to pick among multiple 30 year fixed mortgage rate loans of between 3.5-3.875% (with differing closing costs, points). My first mortgage in the 1990s was 8% fixed.
    • The degree of documentation required to track the liquidation of money from a brokerage account into a savings to close the sale was much more involved than either of the two times I have gotten a mortgage in the past. I would say that it has been around 10 times as hard to comply with the information required (documentation, how specific it had to be formatted) to get a mortgage this time as compared to 6 years ago when we last got one.

    It may have been too easy before, maybe it is too hard now. The Goldilocks principle (“juuussst riiiiight”) is hard to achieve.

    DT

    *This rate is high above the national 14% of home unoccupied and high above the local rate. Not sure why all the ones we considered were unoccupied.

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  • On The Record (with daily recap)

    Today in TIE: Austin on the VA drug benefit and how twitter broke twitter, Aaron on added sugar, while Kevin brings us a leap day win in the fight against tobacco and therapeutic substitution and pharmaceuticals. On The Record just forgot to post yesterday, which I am sure is a bad sign of something.

    DT

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  • IPAB repeal effort heating up again

    Efforts to repeal the IPAB are heating up again in both the House and Senate (overview from KHN; link to a gated Politico Pro story this morning). I reproduce below a post from last Summer that provides a series of links on the recent history of the idea of boards to improve quality and/or address costs (shorter: boards have experts and they do good things if you appoint them; they are bureaucrats and do bad things if your opponents appoint them).

    update: Energy & Commerce health subcommittee voted 17-5 to repeal IPAB (two Democrats joined all Repbulicans in voting for repeal).

    ***********

    I am pulling together several related posts that I have done suggesting that the Independent Payment Advisory Board (IPAB) is similar to two boards proposed in Title VIII of the Patients’ Choice Act (PCA), the most comprehensive Republican health reform plan offered in the 111th Congress. That doesn’t mean they are exactly the same, but does mean that some of the criticism levelled against IPAB by Republican critics is either uninformed about the advocacy for such boards by leading Republicans in the past, or seems hypocritical to me. It is also possible that Republicans have simply changed their mind, but then I would expect them to say that, and to lay out why they recently supported such boards, but no longer do so.

    Both the PCA and the ACA proposed boards that were insulated in some manner from Congress to make health policy decisions. In this way, IPAB is a prime example of a policy idea that ended up in the Affordable Care Act (ACA) that had its genesis in a Republican sponsored bill, or line of policy thought. It is an example of something that appeared to be bipartisan in policy terms (the need for boards insulated from Congress) that became politically toxic once it appeared in the ACA.

    Here are the posts I have written on the topic.

    • General argument that IPAB is similar to the boards suggested in the PCA, from May, 2011.
    • Responding to unelected bureaucrats/unconstitutional charges by showing that boards proposed in PCA were similar in structure, Monday July 11.
    • Focus on what IPAB could do in policy terms as compared to what boards in PCA were proposed to be able to do, Tuesday July 12.
    • Reaction from House Budget Committee spokesman to my blogging, and my response, Tuesday July 12.
    • ThinkProgress did a nice table comparing IPAB to boards in the PCA, Wednesday July 13.

    Other relevant information.

    • Text of the Patients’ Choice Act, Title VIII p. 206-215 are the portions relevant to this discussion. Introduced on May 20, 2009 and co-sponsored by Ryan and Nunes in House; Burr and Coburn in Senate.
    • Text of the ACA, sec. 3403 p. 982-1,033 lays out the IPAB
    • Kaiser has a comprehensive overview of the IPAB
    • Column I wrote on July 24, 2009 in the Raleigh, N.C. News and Observer on the Patients’ Choice Act

    Note: as stated in several posts, there are some Democrats who oppose IPAB as well.

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  • On The Record (with daily recap)

    Today in TIE: Austin with more on creditmongering, a closer peek at redistribution and an estimate of how much Medicare could save by purchasing drugs like the VA does, and Aaron focuses on the PSA test.

    DT

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  • On The Record (with daily recap)

    Today in TIE: Austin notes that Romney refined his Medicare plan, Don on access to taxpayer funded research, and Aaron discusses the relative importance of diet and exercise for weight loss, and takes on the issue of who owns ideas and the linking economy of blogging.

    Over the weekend, TIE had its One Millionth visitor and Harold on how consumers will view health exchanges.

    DT

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