6/13/13 Cancer Treatment vs. Physician Assisted Suicide

I read an ABC news article on-line last night, from 2008 . . . well before Obamacare and the IPAB board was a factor looming in our lives. The article set forth the plight of an Oregon woman, the late Barbara Wagner, and her fight against lung cancer. Here is a link to the article, written by Susan D. James:

http://abcnews.go.com/Health/story?id=5517492&p

Ms. Wagner was a participant in the Oregon Health Plan (OHP) (http://en.wikipedia.org/wiki/Oregon_Health_Plan), a program in Oregon that was set up to cover low-income people otherwise ineligible for Medicaid. It is was and is a program with noble intentions, but less-than-noble practices. This particular case is one where the expense of cancer treatment meets the expense of physician assisted suicide, and the future of someone’s life is decided by bureaucrats based on an economic formula . . . sort of like the scenario one may envision where a very-ill patient under Obamacare will get introduced to the IPAB board.

Ms. Wagner had a recurrence of her non-small-cell lung cancer and the prognosis was grim. She had been told by her oncologist that she was terminal with just a few months to live. The oncologist recommended a new (at the time) drug called Tarceva, which could possibly prolong her life by several months. The OHP’s policy of denying further cancer treatment if the chance of a five year survival was less than five percent kicked in, and Ms. Wagner was denied the drug.

Oregon is a state that has physician-assisted suicide; they call it the Death With Dignity Act. This has been around a while in Oregon, about 15 years, and has been called on remarkably little, though it has some grim applications, as in the case of Ms. Wagner. After receiving the news of her prognosis, and the recommendation of her doctor to take Tarceva as a means of extending her life and not as a curative treatment, Ms. Wagner found herself the recipient of a letter from the OHP advising her that she fell under the the 5%/5% rule denying her the Tarceva and further advising her they would pay for palliative care (hospice) or physician assisted suicide. The Tarceva would cost around $4,000 per month plus the cost of administration since once does not simply purchase the drug but must have it administered in a hospital or chemotherapy infusion center, which likely adds half-again or more to the cost of the drug itself. The cost of palliative care for a few months would be far less, and, as it turns out, the cost for the lethal doses of prescription medications for physician assisted suicide is about $50.00.

This case raised such a nationwide stink for Oregon and its OHP that the decision not to allow her treatment was reversed and she was furnished with the Tarceva. She died three weeks after the Tarceva regimen was started. Granted, in the course of one’s life, which has now come down to the wire, dying today or three weeks from today really makes no practical difference, particularly if the death occurred in 2008 and it is now 2013 . . . just what is three weeks now? Of what significance is it?

There’s not, really. But there is a universe of difference between the hope of the living and the receipt of a letter from your insurer offering to pay for physician assisted suicide. It can be argued that palliative care is a form of suicide, since the fight to prolong life is abandoned and the disease is allowed to run to its terminus while providing as much comfort as possible for the patient . . . but this argument does not really pass muster and is a far cry from an active suicide.

There are many cases in states with no physician assisted suicide (the only states that have it are Oregon, Montana, Vermont, and Washington), where at the end-of-life stage, a caring physician administers heavy doses of pain-killing opiates, a possible side-effect of which could be death. Physicians can do this ethically. There are thousands of prescription and OTC medications that have death as a possible side effect (read the label on aspirin, acetaminophen, and ibuprophen). Morphine is no different, since in large doses, or in some people at any dose, not only can it eliminate severe pain, sending the patient into a comfort-zone unattainable any other way, but does so while suppressing the patient’s respiratory system. I know of at least two cases here in Mississippi where I think the physician felt that death was just hours away and I knew that the doses of morphine being given were rather large. The suppression of one’s respiratory system is why one must be in a hospital setting to receive morphine. Of course it has a tremendous potential for abuse, but it also can kill you and you not even know it, simply by causing you to stop breathing as you sleep peacefully in the arms of Morpheus. If you are terminal and have a DNR (do not resuscitate) order on file with the hospital, they will not intubate you if you stop breathing while under the influence of morphine; you will be allowed to die. Allowing one to die and assisting in their suicide are not ethically the same thing, though the practical result is the same. The semantics of this are at once obstreperous and subtle, but the decisions are left to those on the scene and personally involved in the care of the patient, which is far more cogent than the decision of some distant, bureaucratic board ruling. Oncologists deal with death all the time, and the very personal death of their very personal patients is always taken personally. I admire their ability to cope and whatever means they use to maintain any sort of clinical detachment. I know that my own oncologist, Hemosapien, would be personally touched by my death, even if it were by some means other than my CLL, but certainly more so if my death were attributable to my CLL.

The OHP is a microcosm of what is likely to occur under Obamacare – the cost/benefit analysis of bureaucrats, which under the ACA will be the IPAB board. How this 15 member board will review all the cases that come before it remains a mystery to me. Will their be sub-boards and committees? Undoubtedly! Of course, there will be rules and guidelines but these will be subject to appeal and review. And how will that appeal and review process work? Health and Human Services has already shown a proclivity to waive portions of the law as it deems fit and proper. Will the  scandal headlines that erupt in 2014 after Obamacare’s full implementation, be, “Tea-Party Member Denied Treatment?”

Oddly, the IRS, that same organization that focused on conservative groups to deny or delay 501(c) 3 or 4 tax-exempt organization status, is the entity that will collect the tax one will owe if one is not covered under a qualifying health care plan, and provide the tax credits for those whose income is below a certain level. Their track record is not very good. Nor is that of HHS, whose waivers are cited above, since most of the waivers were granted to labor unions who had plans in effect that did not meet the guidelines of the ACA.

While the IPAB board may not send out any letters advising patients advising patients to consider a physician assisted suicide (as did the OHP), they will certainly send out notices that indicate the cost/benefit threshold of future treatment has been breached, so only palliative care will be allowed for the rest of ones increasingly short life. I’d rather think this was between a person and their physician, not a person and the IPAB board.

Who will be allowed waivers? Will the waivers be automatically granted to some, and denied to others? Will negative press coverage make a difference? It certainly made a difference in the case of 10 year old Sarah Murnaghan, who received a waiver from HHS to allow her to receive a transplant of adult lungs to cure her of her cystic fibrosis. Ms. Murnaghan received her new lungs yesterday and is beginning her hopefully complete recovery in a Pennsylvania hospital today. The entire nation was furious about this, since the HHS rules for transplantation do not allow children under 12 to receive adult donor organs, and young Ms. Murnaghan was an innocent child. Ms. Wagner, on the other hand, was an elderly smoker with lung cancer. Though the cases are different in circumstance, they are not different in practice . . . since both patients had their initial denials waived purely because of negative press. If bureaucrats can waive the law at will, particularly to save face over negative press, then what kind of law is it? What law can be waived for convenience? While the recipients of waivers are grateful for them, what about the people who do not receive the waivers?

IPAB is the acronym for the Independent Payment Advisory Board. By the nature of their name, it will be their job to advise of at least two things, though this is by no means all-inclusive:

  1. Health care providers will be advised how much money they can expect to receive for specific AMA code related procedures. Of course, this will be as customized by market, city, state, and hospital demographics as some of the tattoos I’ve seen on those awful ink programs on TV, and subject to waiver because of bad press or political affiliation.
  2. Patients will be advised that there will be no payment for further treatment since they have passed the event-horizon of what the IPAB says is prudent, subject to modification because of bad-press or political affiliation. While the IPAB may not come right out and advise a patient to move to Oregon to take advantage of its physician assisted suicide program, it certainly will advise a patient of palliative care options that are practically beneficial to the patient and fiscally beneficial to the government.

The more complicated things are, the more potential for abuses. We already have abuses because of the complexity of medical care as it exists today, and we are replacing that complexity with something even more complex . . . a compounded complexity, as it were.

“Let’s pass this bill so we can see what’s in it,” said the seemingly benzodiazepined former-speaker Nancy Pelosi, who is, unfortunately, not-exempt from Obamacare, due to the GRASSELY AMENDMENT, but would like to have herself and her staff exempted since she is among those legislators concerned about the prohibitive costs her staff members will likely face upon its full implementation. If Nancy is concerned about the prohibitive costs her poorly paid staff members will face, well . . . isn’t that one of the things that Obamacare was supposed to address? There are rumblings in the House and Senate about wanting to revoke the Grassely Amendment, but to our great credit, the legislators know that we are watching them. Look for a concerted attempt to postpone (waive) the Grassely amendment before the 2014 implementation of the ACA, or eliminate it entirely after the 2014 elections.

As for Obamacare? We are beginning to see what’s in it, Ms. Pelosi, and through the murk we can clearly discern an exponentially obfuscating bewilderment. Take another diazepam, or two, Ms. Pelosi, and have one of your poorly-paid staff members you’d like to exempt call me in the morning and explain to me why it’s good for me and bad for them. I’d really like to hear someone make a good case for this, as unlikely as it would seem. Stopping a “brain drain” from Washington, DC, is not going to be a part of any successful argument, since it was the aides and staffers that gave us the 1900-plus pages of ACA legislation that no one read, including Ms. Pelosi, but perhaps Senator Charles Grassley, or an aide, who then decided it would be bad form to apply something to all of America and exempt congress and its staffers. Good luck poorly paid staffers and aides ($25,000 to $170,000 per year), as you leave government service and flee to private industry in search of better insurance. I don’t think it’s going to be the mass exodus that some members of congress are claiming. If so . . . then let ‘er bump. What’s good for the goose is good for the gander. Why the implementation of the ACA and its potential higher costs should be bad for aides, staffers and members of congress and good for me is going to be extremely difficult to explain. If we don’t watch them closely, we’ll see their exemption, yet!

I doubt Kathleen Sibelius, in the flesh, can explain it to my satisfaction. That congress is entertaining any inkling that they and their staff members should exempt themselves offers evidence far more compelling than any words of explanation. If their exemption prohibited curative treatments, offering only palliative care, well, then, perhaps I might be able to understand it better. No one offered to mention what health benefits they would be allowed in exchange for their exemption. I suspect it would make me too angry to look and see. I think I’ll join Ms. Pelosi in a diazepam. Maybe that’s the future of medical care . . . give everyone enough diazepam, then they won’t care.

Soma, anyone? Add Huxley’s Soma to Vonnegut’s Ethical Suicide Parlors, coupled with Orwell’s telescreen, and we have a completely horrifying vision of the future. Whew!! I do need that diazepam.

And by the way, the OHP no longer covers cancer treatment at all, but they do cover the cost of diazepam prescriptions and the cost of physician assisted suicide.

Remarkable! 

 

Health and Human Services

Washington, DC.

 

June 13, 2014

 

[Title] [Name]

[Address]

[City], [ST] [Zip]

 

Re: Cost/Benefit threshold exception

Case number: [SSN]-[Threshold Exception Number]

 

Dear [Title] [Name]:

 

Your IPAB case worker has notified your IPAB board that the cost/benefit threshold for your case (number cited above) has been reached. The cost of your medical care has now exceeded and/or is anticipated to exceed any possible benefit your country may realize in the future from your continued treatment for your <{IFYES} [chronic disease diagnosis] {THEN} [Chronic Disease Name];{IFYES} [terminal disease diagnosis] {THEN} [Terminal Disease Name]>; you will be a net drain on society as your age and the seriousness of your illness make it unlikely that you will be able to pay any taxes in the future, or participate in any meaningful value-added way.

 

Your IPAB board would like to advise of the following options available to you, henceforth.

 

1.      Palliative care from an IPAB registered hospice care facility

2.      Free final vacation package, including

ñ   Free one-way bus ticket to Oregon, Vermont, Washington, or Montana

ñ   Up to five days worth of daily meal vouchers (limited to 14 vouchers)

ñ   State residency requirement waivers

ñ   Pre-certified/no co-pay office visit with participating physician.

3.      Appeal of IPAB ruling to the IPAB appeals committee.**

4.      NONE

 

Your IPAB board agent, [Agent Name], is there to serve you and we welcome your input and comments. Please use the our toll-free number (800) 666-IPAB to leave your recorded comments at our personalized automated call center.

 

Yours truly,

 

John R. (Jack) Kervorkian, III, MD

IPAB Executive Director/Under Secretary

Department of Health and Human Services

 

cc: [Case Worker Name], IPAB Case Worker

[IPAB Field Office]

[IPAB ID Number]

(800) 666-IPAB

 

attachments

   Donor form

   Self-Addressed Envelope

enclosures

   “Big Sky Country” travel brochure

   “Sasquatch Country” travel brochure

   “Downtown Montpelier Walking Tour” travel brochure

 

** Be advised that appeals are taking an average 24 months to be heard, except in for accepted accelerated appeals cases, available only to official administration political donors above a certain threshold. Be also advised of the successful reversal rate of rulings on appeal are 0.0015% for conservatives and 44.3% for liberals. You may not have time for an appeal to be heard, nor is their any assurance that your appeal will be reversed, but the likelihood is much greater if you are a political donor. See the attached voter registration/pre-endorsed party affiliation donor form and envelope. Be sure to affix proper first-class postage after enclosing your check and before depositing it in a USPS mail receptacle. Please note the different classifications of donors – Platinum, Gold, Silver, Bronze, Pewter, Pot-Metal, Bakelite, Terra-Cotta, and Compost. While there are no guarantees, a Platinum donor is 5,571% more likely to have his case reviewed within 30 days, and 3,475% more likely to receive a ruling reversal than a Compost donor. Of course, all donations are optional. If cash is not available, a permanent reassignment of the beneficiary on your existing Traditional or Roth IRA is acceptable, as are donations by credit card, provided they meet donor class restrictions.

Morbidly funny? Wickedly prescient? Uselessly cynical? Self-indulgent tripe?

Time will tell.

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