This may be the best advance directive I’ve seen out there. Have you still not set up a plan in case you become extremely ill? How about your family members? Even if you have, how will someone locate the latest plan in the event of an emergency? I think MyDirectives.com has figured it out. It is a cloud-based advance directive that you can even add voice or video to (if you need to do something in another language other than English). You can update it at any time and just give your provider, doctor, hospital, your close family the link to your directive. You can even add information about life insurance and other key information you need shared in the event of your passing. Providers can embed the link into your electronic medical record so that they always have quick access to your latest directive. It can be used and accessed anywhere in the world via the Internet and it is free for consumers and providers to use. Check it out.
I recently heard one of the smartest ideas about how to help make end of life decisions better. This was from a June 17, 2013 Diane Rehm Show on NPR where she interviewed two physicians from Harvard, Angelo Volandes and Aretha Delight Davis. They have created short videos that can be used by physicians to help show patients what it means, for example, to receive CPR when you are 85 and frail or what certain goals of care mean or what it’s like to live with advanced dementia. Instead of relying on every physician to be skilled at having advanced directive conversations, these videos give clinicians an important tool at the bedside to show patients what their choices mean. Visit the Advance Care Planning webpage to see samples of the videos and see segment of Diane Rehm Show below.
But conversely you’ve said that there’s a war on death in this country. Dr. Davis?
Yes. I believe there’s a war on death. As a physician, I am trained to do whatever is necessary to prolong your life. That is true irrespective of whether you are healthy as a patient, or if you’re a patient with advanced disease. That’s the guiding principle, and I will do that until and unless you tell me not too. Now, if you’re a patient with and advanced disease, and you are informed about the risks and the benefits of these interventions, and that’s how you would like for me to proceed, great. I have my marching orders. I know what I need to do.
But if you aren’t, and if you have not translated your values, your wishes, the core of who you are into some sort of medical plan, unfortunately what I will do is often times provide marginal benefit, cause great suffering to you and your family, and frankly, only postpone your death.
So Dr. Volandes, how did the idea of these videos come to you, and how did you proceed?
Sure. The story behind the videos began about a decade ago this month in fact. I was a first-day intern in residency, and I was admitting to the hospital one of the University professors of English. She had widely metastatic cancer. So I did my history, I did my physical, and then I got to that point in the conversation that all doctors have a tough time with, talking about goals of care, CPR, breathing machines.
So she looked at me and she said, Angelo, what would you do if you were in my shoes. What would I do? I was a first-day intern. Just yesterday I was a medical student, and today I’m Volandes. I had read and studied these things, goals of care, CPR, and breathing machines, but I didn’t have much experience with it. So I told the professor, well, professor, I think it’s important that we have a forest from the trees perspective, that we think about the risks and benefits for each of these interventions, but that we come to an understanding of where you are on your journey with this disease.
And then she gave me that blank look that probably all my patients gave me that first day of internship, and so I asked her naively, I said, professor would you mind taking a walk with me down to the intensive care unit so I can show you some of these things? Of course she obliged. We didn’t walk down to the ICU, I put her in a wheelchair and rolled her down to the ICU where she got to see a breathing machine. She got to see a patient on a vent. The professor was able to get a sense of the place, to hear the beeps and buzzes, to see the colorful monitors, to feel the rhythm of the ICU.
Well, as fate would have it, I obviously didn’t plan on this, but there was a code blue that was called in the ICU while we were there, and that’s when a very nervous intern thought he was going to get fired on his first day on the job. So I took the professor out of the ICU, but not before she caught of few glimpses of CPR. When we went back to her room, she looked at me and she said, words, words, words. Angelo, I understood every single word that you said before, goals of care, CPR, comfort care. I am after all a professor of English. But I had no idea that’s the sort of thing you were talking about.
Steve Lopez March 31, 2012
Debbie Cassettari had outpatient foot surgery to remove a bone spur. She arrived at the surgery center at 8 a.m., left at 12:30 p.m., and the bill came to $37,000, not counting doctor fees. In recovery now from sticker shock, she’s waiting for her insurance company to do the tango with the clinic and figure out who owes what to whom.
Gary Larson has a $5,000 deductible insurance plan, but has found that his medical bills are cheaper if he claims he’s uninsured and pays cash. Using that strategy, an MRI scan of his shoulder cost him $350. His brother-in-law went to a nearby clinic for an MRI scan of his shoulder, was billed $13,000, and had to come up with $2,500.
Kaiser member Robert Merrilees had a colonoscopy at an affiliated surgery center, which charged $7,500. His co-pay was $15, Kaiser picked up $470, the rest of the bill “just went away.” Merrillees was left scratching his head over the crazy math in medical billing.
There is lots of head-scratching out there, and stories like these have poured in from across Southern California and beyond since I wrote last week about an 11-year-old girl and her $5,000 trip to an emergency room with a stomachache.
I heard from medical professionals who said fear of lawsuits leads to lots of play-it-safe tests and procedures. And some doctors and nurses argued that emergency rooms have to charge high prices because it’s extremely expensive to operate them 24 hours a day.
No doubt. But the larger point in last week’s column was that the calculus for medical charges in general is beyond comprehension, with outrageously high fees used as a starting point in a bizarre game of bargaining. Glenn Melnick, who teaches hospital finance at USC, told me it’s as crazy as if he asked to buy the TV in my living room, and I gave him a price of $1 million to start the conversation.
This is the kind of insanity that exists when medicine and medical insurance are about private profit rather than public health, when 50 million people are uninsured, when Medicare and Medicaid reimbursements don’t always cover true costs and when polarized politics prevent the kind of reasonable discussions that could lead to solutions.
In the case of Ella Moser, her grandfather — a physician and Yale professor who has written about medical overcharging —questioned the procedures that were done and the fees that were charged when she was treated in October at Providence Tarzana Medical Center. You can’t talk about rising healthcare costs and healthcare reform, he argued, without making both of those elements part of the discussion.
Ella’s father, John Moser, had a $5,000 deductible plan with Cigna, and had taken Ella to the hospital to rule out appendicitis. Nothing serious was diagnosed, and Ella went home to a quick recovery. Her dad got a bill for nearly $5,000 from the hospital, as well as bills for $540 from a pathologist and $309 from the doctor who treated her.
Like Moser, lots of patients are surprised to get separate bills like that, unaware that a hospital’s doctors can be independent contractors. It’s like going to a Laker game, paying $150 for a ticket, and later getting an additional $75 bill in the mail from Kobe Bryant.
Because of Moser’s deductible, Cigna paid no part of his bill. But the company’s contract with the hospital includes agreed-upon discounts, and those were passed on to Moser.
Just entering the emergency room had been billed at $1,288, for instance, but Moser paid Cigna’s negotiated rate of $682.64. The total charges, nearly $6,000, ended up costing him closer to $3,000.
But like his father, the doctor, Moser was left with lots of questions. How can you trust a business that bills you $1,288 but is happy to collect $682.64? Is the second number also arbitrary and perhaps artificially high? Hospitals argue that list prices are high to compensate for patients who don’t pay, but how can any patient on that spectrum know whether he’s getting a break or being ripped off?
A single-payer system would address some of this nonsense, but forget it. Even President Obama’s watered-down healthcare reform act, which may well die on the Supreme Court’s operating table, couldn’t be passed if it came up for a vote now.
Joseph Mondy, a Cigna spokesman, had some tips for anyone trying to avoid medical bankruptcy from an emergency room visit. Contact your health plan’s on-call nurse for advice on whether you need to visit an emergency room, consider a less expensive urgent care clinic if one is available, go to an in-network emergency room if possible and ask the doctor to explain why certain tests and procedures are necessary. Good advice I’m sure, but there’s not always time for all that in a genuine emergency.
Dr. Phil Schwarzman, medical director of the emergency department at Providence St. Joseph Medical Center, said 15 million of the nation’s uninsured people live in California, and he sees lots of them. From his front-line perspective, he finds it unconscionable that so many Americans have been driven into bankruptcy from medical costs, and he thinks mandated healthcare for everyone would restore some sanity to pricing.
And he speaks not just as a physician, but as a consumer.
Schwarzman has an insurance plan with a high deductible ($7,000). Like Gary Larson (the guy at the top of this column), Schwarzman also paid about $350 for a scan on himself that would have cost much more if he went with his insurance company’s negotiated rate. A couple of years ago, his daughter needed an ultrasound for a possible gallstone. If he’d gone through his insurance company, he would have been charged $3,200, with insurance paying $1,500, leaving him a $1,700 bill. He chose instead to leave insurance out of the equation and pay cash instead. The price was $250.
“It’s outrageous,” Schwarzman said. “I don’t know where they’re coming up with these numbers. Are they picking them out of a hat?”
Listen in to Kenn Fox Live! 102.5 on Monday March 26 starting at 12 noon EST for an interview we did recently about how to improve end-of-life care and long term care in the U.S. You can listen via the Internet at 102.5 The Renegade. Just go the website and click on Listen Live. He’s got a great show everyday from 10 to 2, you might just get hooked!
This site is currently in development. Stay tuned for commentaries on current events related to life, death, and modernity from students of Anthropology 6506 at George Washington University starting September 2012. For more information, see About.
Come join me for the Society for Applied Anthropology Awards Ceremony and reception in Baltimore, MD. I will be there celebrating receipt of the 2011 Margaret Mead Award and signing copies of my book, The Maintenance of Life (2009). Come help me celebrate!
What: The Society for Applied Anthropology 72nd Annual Meeting, Awards Ceremony
Where: Sheraton City Center Hotel, Hospitality Suite #2727, Baltimore, MD
When: 6:30-7:30PM on Friday, March 30, 2012
Please RSVP at firstname.lastname@example.org.
I like anything that gives us more options for independent living. Check this out.
Read the Article at HuffingtonPost
Check out this video. It is a lecture by Eric Dishman, researcher at Intel, where they focus on technology and innovative solutions for people who are aging.
Allen Young, who runs his own blog for students of gerontology, just posted a great article that links to forums where you can talk to others on almost anything you need to know about long term care and “healthy aging,” or on how to create better options for living as we age. Are you looking for long term care options for yourself or your parents? Do you have questions about Medicaid or Medicare? Do you know want to know more about how other countries solve their long term care problems? Check out Allen Young’s 40 Informative Forums on Long-Term Elderly Care.