"Death panels" are back in the news, and Congress is turning its attention to them once again. The problem is, lawmakers are looking in all the wrong places.
The House Energy and Commerce Committee, now headed by Republicans, sent a letter to Health and Human Services Secretary Kathleen Sebelius last week demanding to know how a controversial provision that was excised from last year's health reform bill wound up -- briefly -- in a government "rule" on physician reimbursement.
The proposed provision would have allowed Medicare to pay doctors to counsel patients about their end-of-life medical wishes. That idea originally had bipartisan support, but when the provision was brought to Sarah Palin's attention, she accused Democrats of wanting to create "death panels" that would decide when to pull the plug on granny and grandpa.
The claim was utterly false, but it was such an irresistible soundbite that Palin posted it on her Facebook page. She and many other Republicans quickly made it a central part of their efforts to scare people away from health care reform. They were so successful -- it spread like wildfire through the online and cable news worlds -- that PolitiFact.com, the fact-checking website of the St. Petersburg Times, chose it as the "Lie of the Year" for 2009.
Worthy as the idea of paying for end-of-life counseling might be, cowed Democrats pulled it from the reform bill before it reached President Obama. Last November, however, the provision was included in a rule that was issued by Medicare on physician payment rates. When the rule became public, Republicans pounced once again. The Obama administration pulled the provision immediately, dropping it like the political hot potato it had become.
In their letter to Sebelius last week, Republicans on the Energy and Commerce Committee charged that the administration had attempted "a political maneuver designed to avoid public scrutiny."
Raising this issue again is part of a larger strategy by Congressional Republicans to further erode public support for reform, to keep it alive as a divisive political issue. Meanwhile, the business of real death panels is proceeding as usual, outside of any public scrutiny or apparent interest on Capitol Hill.
Yes, death panels do exist. They exist inside the big health insurance corporations that every day make decisions on whether or not people enrolled in their health benefit plans will get the care their doctors believe might save their lives. I know this firsthand from nearly two decades inside the insurance industry.
You don't have to take my word for it. Just ask Hilda and Grigor Sarkisyan, who very possibly would be helping their daughter, Nataline, plan her 21st birthday about now had a corporate medical director not refused to pay for a liver transplant Nataline's doctors believed would save her life.
Nataline was diagnosed with leukemia at 14. Initial treatments were successful and the disease went into remission. It came back a couple of years later, though, and the sort of treatments she'd had previously were not working. She had to have a bone marrow transplant, which weakened her liver. In mid-December 2007, her doctors at UCLA Medical Center said she needed a liver transplant. They asked for prior approval from her insurer, CIGNA, to pay for it. Nataline's doctors said they believed she had at least a 65 percent chance of living five years or longer if she had the procedure.
A CIGNA medical director 2,500 miles away in Pittsburgh disagreed. To the astonishment of Nataline's doctors, he ruled the transplant "experimental." Insurers almost never pay for procedures they consider experimental, so this corporate medical director's decision meant that the Sarkisyans would have to pay for the transplant and all related care out of their own pockets. Not being wealthy enough to do that, Nataline's parents launched a campaign to rally public support and media interest in the case. It worked. CIGNA eventually agreed to cover the transplant. Unfortunately, so much time had passed since the original request had been made that Nataline's other organs began to shut down. She died a few hours after the family got the news that CIGNA had changed its mind.
As chief spokesman for CIGNA at the time, I was on the receiving end of hundreds of calls and emails from reporters and also from regular folks who were outraged that CIGNA had initially refused to pay for Nataline's transplant. The Sarkisyan family sued CIGNA, but the case was thrown out because of a Supreme Court precedent that shielded employer-paid plans from damages resulting from their decisions.
I wish I could say that Nataline's story was unique. In the course of my 20 years in the industry, however, I handled media inquiries involving many cases in which coverage had been denied by a corporate medical director for one reason or another. I probably will never know how many of those people died as a result of not getting the care they needed, and I will never know if Nataline would have lived if she had gotten the liver transplant when her doctors wanted to do it. I will also never know if she might have gotten the transplant if she had lived in Canada or England or France, countries that do not permit doctors at for-profit corporations to make such decisions.
What I do know is that medical directors at insurance companies are corporate executives, just as I was. When you work for an investor-owned insurer, you're aware that you must do your part to assure that the firm meets Wall Street's relentless profit expectations. Medical directors don't get memos from the CEO saying they have to deny a certain number of transplants every month, but they do get the message that if they don't help the company keep medical spending down, they can forget about getting a raise or bonus or stock options at year's end.
Last year, when Democrats were in charge of Congress, the House Energy and Commerce Committee conducted an investigation into denials of coverage in the private insurance market, although the investigation was limited to denials for pre-existing conditions. The committee found that over a three-year period, the four big insurance companies it investigated had denied coverage to more than 600,000 people who had been treated in the past for a broad range of medical conditions and that the number of coverage denials had increased significantly each year. The lawmakers found that one of the companies maintains a list of 425 medical diagnoses that it uses to refuse health insurance coverage permanently to many applicants.
The results of that investigation led lawmakers to include in the health care law a provision barring insurers from using pre-existing conditions to deny coverage.
If the lawmakers who are now leading that committee were truly interested in looking out for the best interests of their constituents, they would drop their politically motivated probe into the end-of-life counseling provision and launch a new investigation of the death panels inside private insurance companies.
One of the people they might want to call to testify is the former chief medical officer at Aetna, Arthur "Abbie" Liebowitz. In an interview for a report written last year for the Center for American Progress, Liebowitz explained the pressure that is exerted on corporate medical directors -- medical directors who now report to regional business managers, rather than chief medical officers, as was previously the norm.
"The concept was that business leaders had P and L (profit and loss) responsibility for the region," Liebowitz was quoted as saying. "The business guys said if I have responsibility for profits and losses I have to control for the things that account for my costs. The biggest things affecting cost was medical cost delivery."
Liebowitz said he fought the change in reporting relationships "until the very end." He left Aetna in 2001.
"I didn't think that people should be making medical decisions based on business needs."
Neither do I. I saw the life and death consequences of that on a regular basis. If the House Energy and Commerce Committee doesn't think this is important enough to look into, maybe the Senate will.
(This also was published by the Center for Public Integrity at publicintegrity.org.)
Follow Wendell Potter on Twitter: www.twitter.com/wendellpotter
You missed a a very important death panel that has nothing to do with insurance companies.
Before I point that out, perhaps you might have mentioned that insurance companies routinely deny cases. Between 10 to 15% maybe higher now. Based on their experience that many will go away.
The Death Panel I'm referring to is the Tea Party and the GOP, who if left to their own devices would eliminate Health Care while giving corporations more tax cuts.
In congress, the battle isn't about money, entitlements, bills etc, it's about power, with little or no consideration for women or families or the middle class.
The GOP assault against women is even more ferocious than the one against the middle class.
Again, thanks for a well contemplated and well written article.
In Canada, someone like Nataline would have been essentially pre-approved for a transplant. The only thing indefinite would have been finding a donor, but since liver tissue can be obtained from a living donor, that could have happened in time.
I am reading your book right now! It's pretty good!
Best Regards,
G&M
I'd rather not take my chances on a government committee.
And I am certainly not a fan of so-called Obamacare, which is corportist Republican scheme that preserves the existing for-profit system!
It is a very common human failing - Confirmation Bias.
This is quite complicated, I'm not a lawyer, so hopefully you will point me to the incontrovertible truth you claim to possess. link please.
After seeing care in countries with universal health care and the rudimentry system we have here, it is amazing that many Americans are alive. In other countries there are not gatekeepers approving or denying care patient by patient. Decisions are made by the doctors and the patient. In the US the decision is made by a high school graduate with a loose leaf binder.
It is not against the laws of nature to mandate that medical insurance companies provide care. It is not against natural selection to regulate businesses to live up to their contracts. What is against natural selection is to allow the insurance companies exemptions from being sued if they flagerently abuse the medical practices they have taken upon themselves. What is against natural selection is allowing insurance companiies to collude to set prices, to assign territories they will choose to sell insurance in and to cover up their practices.
There is no more a need to have insurance companies than there is to have legal companies that commit arson for hire or will off your spouse for profit.
I have lived where there is government health insurance for all, much better than the care you get in the United States. If you want gold plated insurance it's tightly regulated as well.
The US model is most inefficient , provides the worst care and is the most expensive.
Are the doctors offices as plush, probably not, slightly less designerish. But for actual care, far superior, more responsive, quicker, and the doctors don't have to get approval if they want you to see a specialist. Outstanding care in both Canada and the UK. Fair to poor in the US.
As for doctors being reimbursed for counseling patients, that's absurd. Doctors are reimbursed for office visits for medical care, or for bedside visits to inpatients, and they get a lot of money for their ten minutes. A separate charge for a conversation on health care directives is obscene.
Providers are reimbursed for services like office visits and inpatient visits, not reimbursed based on the specific content of the exchange between patient and doctor, things like end-of-life health care options.
Claims of death panels is worthy of response. A lie not denied becomes the perceived truth.
Instead of quality of life?
But it's not to absolve medical providers who spend $700 billion a year not practicing "Best Medical Practices".
It really all depends upon what kind of society in which you wish to live ...
And you're argument is as fallacious as claiming if I do not give you my car I denied you a car. Dealing with insurance (outside the meddling of gov) is a free will exchange. Gov mandated an monopolized health care is not... its FORCE.
Yes an insurance company can say NO to me for a cure and most likely will weighing cost etc. But the difference is the insurance company not a monopoly I HAVE TO do business with NOR is it a monopoly that is the ONLY GAME IN TOWN. If they say NO I can go to another insurer or I can somehow dig up money or go to a charity. Its not perfect but I can try alternatives.
With gov run health care not only does the gov have a monopoly on treatment but also WHO can practice medicine. So if they say NO I can't even get a doctor to perform the procedure IF I had the money.
A free will insurer saying NO is no more oppressive than reality not teleporting apples into your mouth cause you're hungry.