Concerning Section 1233

Charles Lane is right: linking Sec. 1233 to euthanasia is “rubbish.” But his own concerns about the government bribing physicians to bully patients into signing DNR orders don’t have much more basis in reality than Sarah Palin’s rantings.

Every time a physician offers a patient a medical service that the physician provides, the physician stands to gain financially if the patient accepts. In some sense, that constitutes a “financial conflict of interest.”

But the mind of Charles Lane, allowing Medicare to pay for end-of-life counseling, and requiring a physician who provides such counseling paid for by Medicaid to mention the full range of options, including hospice care, would “skew” the patient’s decisions about accepting counseling and about executing an end-of-life order.

… the measure would have an interested party – the government – recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations. You don’t have to be a right-wing wacko to question that approach.

Maybe you don’t have to be a right-wing wacko to worry about this question. But it sure helps. The proposal would allow Medicare to pay for a badly-needed service, and specify in a reasonable amount of detail what that service includes. The fact that the physician will get paid Medicare doesn’t make the physician an agent of the government in doing the counseling, any more than he’s an agent of the government in doing a colonoscopy. Nothing in the bill requires or even encourages the physician to “sell” anything. Indeed, the physician’s incentive would seem to be to administer the counseling as quickly as possible, without taking the time to actually execute a document.

Lane continues:

Section 1233, however, addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they’re just trying to facilitate choice – even if patients opt for expensive life-prolonging care. I think they protest too much: If it’s all about obviating suffering, emotional or physical, what’s it doing in a measure to “bend the curve” on health-care costs?

That’s an interesting question. Rather, it would be an interesting question if its factual predicate were accurate. In fact, section 1233 is in Title II of the bill, labeled “Medicare Beneficiary Improvements,” No part of Title II has anything to do with cost containment; it’s mostly about easing eligibility rule, increasing subsidies, and decreasing premiums. A list of all the section headings in that Title appears after the jump; the two sections immediately adjacent to 1233 cover extending immunosuppresive therapy for kidney-transplant recipients and making it easier for families of servicepeople covered by TRICARE to enroll.

Ken Anderson expands on Lane’s point, spinning a fantasy about how Seciton 1233 would “nudge” patients toward an early check-out, according to the preferences of a bunch of technocrats. But Anderson, like Lane, never explains how this is supposed to work. Even assuming that the payment for the service will be high enough to tempt phsicians into “insisting” that their patients receive it, it’s still not clear how the eeeeevil social engineers in the White House are going to bribe them to bully their patients into signing DNR orders.

Lane starts out his essay by acknowledging that the teabagger/Sarah Palin “Obama gonna kill yo mama” take on Section 1233 is “rubbish.” Good for him! But having identified a paranoid idea which is developing serious political legs, he then spends the rest of the column trying to work himself up to the belief that there’s something real behind the paranoia. All in all, a bizarre performance.


Subtitle A—Improving and Simplifying Financial Assistance for Low Income

Medicare Beneficiaries

Sec. 1201. Improving assets tests for Medicare Savings Program and low-income

subsidy program.

Sec. 1202. Elimination of part D cost-sharing for certain non-institutionalized

full-benefit dual eligible individuals.

Sec. 1203. Eliminating barriers to enrollment.

Sec. 1204. Enhanced oversight relating to reimbursements for retroactive low

income subsidy enrollment.

Sec. 1205. Intelligent assignment in enrollment.

Sec. 1206. Special enrollment period and automatic enrollment process for certain

subsidy eligible individuals.

Sec. 1207. Application of MA premiums prior to rebate in calculation of low

income subsidy benchmark.

Subtitle B—Reducing Health Disparities

Sec. 1221. Ensuring effective communication in Medicare.

Sec. 1222. Demonstration to promote access for Medicare beneficiaries with

limited English proficiency by providing reimbursement for culturally

and linguistically appropriate services.

Sec. 1223. IOM report on impact of language access services.

Sec. 1224. Definitions.

Subtitle C—Miscellaneous Improvements

Sec. 1231. Extension of therapy caps exceptions process.

Sec. 1232. Extended months of coverage of immunosuppressive drugs for kidney

transplant patients and other renal dialysis provisions.

Sec. 1233. Advance care planning consultation.

Sec. 1234. Part B special enrollment period and waiver of limited enrollment

penalty for TRICARE beneficiaries.

Sec. 1235. Exception for use of more recent tax year in case of gains from sale

of primary residence in computing part B income-related premium.

Sec. 1236. Demonstration program on use of patient decisions aids.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: