Apparently my numbers for the doughnut hole were low on both ends, but the size and existence of this gap depends on which Medicare Part D a beneficiary is enrolled in.
Now we're looking at Title II: Medicare Beneficiary Improvements. Subtitle A is about improving and simplifying financial assistance for low income Medicare beneficiaries. Although Medicare is generally a MUCH better deal than any private insurance, beneficiaries are still responsible for a certain number of expenses themselves, so low income individuals are eligible for some subsidies. There are the so-called "dual eligibles" who are eligible for both Medicare and Medicaid.
Subtitle B is about reducing health disparities. Provisions include insuring effective communication, such as by providing reimbursements for linguistically and culturally appropriate services.
Subtitle C contains "Miscellaneous Improvements". They do seem pretty miscellaneous. For example, the months of coverage for immuno-suppresive drugs for kidney transplant patients is extended.
That brings us to Section 1233: Advance Care Planning Consultation.
The term "advance care planning consultation" is defined as a "consultation between the individual and a practitioner...regarding advance care planning, if...the individual involved has not had 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 beern 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 traning 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 stake-holders 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; and (B) a nurse practitioner or physician's assistant who has the authority under State law to sign orders for life sustaining treatments.".
That's a lot of text, but I think it's very important to look very closely at what the actual text says (and keep in mind the concept of an advance planning care directive was bipartisan until Sarah Palin came out with the death panel nonsense).
In the first place, these consultations are not mandatory. All the language says is that physicians can be reimbursed, no more than once every five years unless there is a serious change in medical condition, by Medicare for such consultations.
In no way is the practitioner or the government dictating end of life care. The provider is to explain the options available. How dare practitioners tell patients they can name a legal surrogate in case they are incapacitated!!!!!!
Frankly, I don't see how this is not a GREAT idea. Seniors have a right to know their rights. If they decide that they want great medical lengths to be taken to preserve their life, so be it. If they would prefer hospice care, they have a right for that preference to be known and honored.
Personally, I almost feel like I should have a living will drawn up soon. I do not want extraordinary measures to be taken to preserve my life, even as a relatively healthy 21-year-old, if its quality will be severely diminished.
Critics of these consultations say that we are "trying to pull the plug on Grandma". End of life care, particularly in hospitals, is expensive, no doubt about that. These costs will continue to go up as health care advances and the Baby Boomers continue to age. But we're not dictating care! And in no way is this euthanasia! All the bill says is that once every five years, a Medicare beneficiary can have a consultation with a physician about their OPTIONS.
Some may OPT to create an "order regarding life sustaining treatment", which is defined as "an actionable medical order relating to the treatment of that individual that-- (i) is signed and dated by a physicial 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)".
How dare we document these preferences, which "may range from an indication for full treatment to an indication to limit some or all specified interventions".
This information would also be published in the "Medicare & You Handbook" distributed to beneficiaries.
Maybe it's me, but I don't detect anything sinister.
At all.
I think it would be a shame for someone who would want to have his preferences known not able to create such an order because he would have to pay his physician out of pocket for it.
There are a few other provisions, but basically that brings us to page 443 and Title III.
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