It’s never too early to discuss your final wishes

(The Tennessean, September 22, 2013)

By Manoj Jain, M.D. and Sen. Bill Frist, M.D.

A week before my (Dr. Jain) elderly parents came for a long visit, I asked them if they would be willing to have a conversation about end-of-life planning. But it wasn’t until the day before they left that we sat at the dining table with documents I had printed from the Tennessee Health Department website.

Too often among family, such end-of-life conversations do not occur. Studies show that 60 percent of people say they do not want to burden their families with difficult end-of-life decisions. More than 80 percent of people agree that it is important to have end-of-life instructions in writing. Yet less than 25 percent of people have followed through with written directions to ease the burden on their family members.

Why do we not have this crucial conversation? Talking about end of life is certainly uncomfortable. Yet, there may be an even greater fear. Talking about death may be akin to opening Pandora’s box, or being perceived as someone who is encouraging or wishing for our loved one to die.

But by having a conversation about death, we are not inviting or encouraging death for our loved ones, we are profoundly affecting how the end of life will be experienced by everyone involved — both the individual whose wishes are to be respected, and all of the family members who carry their memory forever.

I (Jain) feared that my parents might misunderstand my intentions. As we sat at the dining table, I broke the ice by talking about the death of my grandfather at 93, and how he was clear in his wishes not to go to die in a hospital. My father then told me how he spent the final day and hours with his father, sitting with him. As our conversation went on, I realized that my parents, too, had desired to have an end-of-life conversation.

Whether you are concerned about an elder family member, or preparing to share your own end-of-life wishes, there are resources and tips to make the conversation easier.

Starting the conversation

Approach the topic directly and gently. Start the conversation with plenty of time, on common ground, perhaps by discussing a shared experience. Confirm your desire for a family member’s wishes to be honored, for their dignity to be preserved.

The Tennessee Department of Health provides further guidance for this conversation in its “Five Wishes” resource. More than 18 million “Five Wishes” packets have been distributed.

A structured document called an advance-care plan, or living will, can help guide the conversation. While it is a legal document reflecting our wishes, an attorney is not required to draft it or sign it. In Tennessee, advance-care plans are available online: http://health.state.tn.us/advancedirectives/.

An advance-care plan requires three major decisions. First, an individual must name an agent. A health care agent is a person who will make health care decisions for you. You can make this effective at any time. An agent is usually a trusted friend or relative who you feel will make the best decisions on your behalf.

Next, an individual must determine how he or she defines quality of life in the final days. You decide which conditions are acceptable to you: permanent unconsciousness, such as in a coma; permanent confusion, like end-stage dementia; or dependency for activities of daily living. These are not easy decisions, and over time your opinions may change. Having a frank and thoughtful conversation about your wishes will empower your family if any of those situations arise.

Treatments and Interventions

Finally, individuals must decide which treatments and interventions they would like to take advantage of. At the end of your life, do you wish to receive CPR? Life support? Surgery? Tube feedings? Advance-care plans offer explanations and definitions of each option. If you have questions, your local doctor or nurse can help.

The final product — a two-page document — will be notarized or signed by two witnesses. Then copies should be shared with your physician, your health care agent and close relatives.

Culturally, it is hard for us to talk about and prepare for death, but taking the time to prepare now will be invaluable for you and your family later. Conversations about end of life do not need to be single, marathon affairs. Express your wishes, do your research, discuss again as circumstances change. It is never too early to agree together to a plan, but it could be too late.

 

Dr. Manoj Jain is a Tennessee doctor who writes for The Washington Post. Dr. Bill Frist is a heart transplant surgeon and former U.S. Senate majority leader.

This article was originally featured in The Tennessean http://www.tennessean.com/apps/pbcs.dll/article?AID=2013309220100

Premium Support is the Only Way to Fix America’s Medicare Mess

(The Week, March 27, 2012)

By Bill Frist, M.D.

To save Medicare — and rein in our national debt — we must transform the entitlement program into a defined-contribution system

Nothing is scarier than losing your health.

A close second, however, is getting sick and not being able to afford the care you need. For seniors, Medicare has been the entitlement program that for 47 years has dependably provided health security and peace of mind.

But today, demographics are shifting. Fewer workers are contributing to the pay-as-you-go system that by 2030 will cover double the number of beneficiaries it does now. Those reaching 65 this year, on average, will take out in services more than twice what they paid in over their lifetime. That is simply unsustainable. Medicare cannot last as currently configured.

Absent real changes, Medicare will be unable to meet the needs of seniors in the future.

And looming behind all this is our nation’s debt, skyrocketing on autopilot from $15 trillion today to $22 trillion in eight years. The higher the debt, the slower our economy grows, and the fewer jobs are created. Though a lot of people think Social Security is the culprit, it is not. As a percentage of GDP, it is our two government health programs, Medicare and Medicaid, which, left unchecked, will disproportionately balloon over the next 50 years.

For these reasons, the single most important reform that our next president must address is Medicare modernization.

Absent real changes, Medicare will be unable to meet the needs of seniors in the future.

This week marks the two-year anniversary of the President Obama’s health reform initiative. But that law did little to reform Medicare. Instead, it primarily addressed an entirely different issue, increasing access and expanding Medicaid so that one out of every four Americans will be on Medicaid in 36 months. Structurally, President Obama did not change Medicare at all.

If demographics, determined years in advance, define the impending bankruptcy of Medicare, why haven’t our elected leaders acted? Well, in fact, both President Clinton and President Obama, under mandates by Congress, appointed high-profile presidential commissions to address the issue of entitlement reform and Medicare modernization.

The irony is that both bipartisan commissions, one in 1998 and the other in 2010, demonstrated majority support for the exact same type of fundamental reform for Medicare, a plan that maximized security for our seniors, choice for the individual, and longterm sustainability of the program.

It’s called premium support. Here is how it would work:

When you become eligible for Medicare at 65, you choose a health plan from a menu of integrated private plans that all cover the basic benefit package provided under traditional Medicare today. They can vary in depth and scope of additional coverage. Or you can choose to keep traditional Medicare instead of choosing one of the more modern plans. It’s your choice. All the plans and the exchange system through which they are selected are regulated by the federal government to guarantee security, fairness, and accountability for the individual and a level playing field for the plans.

Your premium for the coverage will be paid partly by the government (known as a defined contribution or premium support). For example, hypothetically, this year the government might pay $8,000, and you pony up a supplementary sum — the total would depend on the additional benefits of the plan you selected. Your personal contribution would be means-tested, with more aggressive subsidies paid for those without resources to afford the basic coverage. The premium support level would be adjusted by income, geography, and health status. You would be able to afford it.

Is such a transformation of Medicare risky? Not really.

The government has a whole lot of experience successfully managing such an exchange, transparently ensuring its equity and value. It has been doing so with the FEHBP (Federal Employees Health Benefit Plan) for the past 52 years. This system has insured all federal employees, currently covering 9 million people, including me when I was a senator — making it the largest employer-sponsored group health insurance program in the world.

The advantages of premium support are many.

Each senior is empowered with a choice of comprehensive plans, similar to what each member of Congress enjoys. Plans can rapidly adopt improved innovations in benefits and coverage rather than wait years for Washington to pass another law. And increased price transparency demanded by active consumers interested in making a value-based choice of plans will empower 50 million Americans to powerfully participate in reducing waste, continually squeezing the fat out of the system.

Premium support would reduce total spending by stimulating price competition among plans (just as has been observed with the Medicare prescription drug coverage structure created in 2003). Beneficiaries become more cost conscious in choosing a plan that best suits their needs.

No longer would doctor and hospital reimbursement be determined by Washington-based price fixing (and arbitrary, blunt, across-the-board cuts) but rather, by value to beneficiaries. No longer will federal centralized pricing of 155,000 service codes based on episodic and unpredictable review be necessary. A side benefit would be a reduction in the costly and distorting power of lobbyists and Washington-based special interests who thrive on managing this centralized price setting to their advantage.

Premium support makes Medicare sustainable longterm, and goes a long way toward reversing the debt and entitlement problems that threaten America’s future.

And what are the naysayers worried about? First, they say providing seniors with more choice is just too confusing. But seniors can keep what they have in traditional Medicare if they want. Second, they argue premium support simply shifts costs and does nothing to reduce the overall price of care. But aligning reimbursement with value and quality rather than quantity will minimize this shift.

The premium support concept is neither novel nor new. Initially proposed in a bipartisan spirit by two congressmen in 1983, endorsed by two prominent health policy economists in 1994, supported by a majority of both of the last two presidential commissions, and more recently proposed by members of both political parties in Congress, premium support is the leading solution to achieve Medicare modernization for seniors and fiscal solvency for our country.


Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books.

 

This article was originally featured in The Week http://theweek.com/article/index/226065/premium-support-is-the-only-way-to-fix-americas-medicare-mess