White Coat Underground

Last night’s Daily Show was hands down the best discussion of the health care reform insanity on TV, radio, or web. What interested me the most was how McCaughey revealed some of her real agenda, and how she actually brought up some almost-right points. Even more surprising, Jon Stewart misunderstood some bits that need fleshing out, so here we go.

We’ve met McCaughey before as the right wing wacko pushing the death panel idea. She does a good job hiding her real agenda for a while with Stewart, insisting on her support for public health care, and for end-of-life discussions. Let’s review her words from Rush Limbaugh’s show:

The health care reform bill “would make it mandatory — absolutely require — that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner.”

In her interview with Jon Stewart, she’s a bit more careful with her words. What she does is draw a line from reimbursement for end-of-life counseling to practice quality measures, to physician incentive payments, implying that this tenuous line will lead to “bad things”.

What Stewart missed was the whole “quality measure” thing. Medicare has a program called PQRI in which they collect data on quality of care and reimburse physicians who track these measures (many physicians, myself included, believe this really means that we will only be given full payment for tracking PQRI). For example, if I track data on whether my diabetics are offered certain tests, have their blood pressure checked, etc., I get a bonus payment (supposedly). At this point, I don’t get penalized for bad blood pressures, or rewarded for good ones. The only reward is in the tracking.

HR 3200 does add a PQRI clause to advanced directive counseling, which, it may be argued, incents physicians to have these conversations and document them. The language that McC claims is “dangerous” is this:

(b) Expansion of Physician Quality Reporting Initiative for End of Life Care-

(1) Physician’S QUALITY REPORTING INITIATIVE- Section 1848(k)(2) of the Social Security Act (42 U.S.C. 1395w-4(k)(2)) is amended by adding at the end the following new paragraphs


‘(A) IN GENERAL- For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.

The section I’ve bolded is the one McC keeps bringing up. It is the key to her line of reasoning—if this is included in quality measures, then it will be included in incentive, therefore doctors will coerce patients from changing their minds about advanced directives, which might lose them credit for “adherence”.

This reasoning seems tenuous because it is. It’s ridiculous. What McC says (at time marker 16:53):

Putting pressure on doctors to require patients to go through a consultation that’s prescribed by the government, and then penalizing them if the patient or family changes their mind about their living will in a moment of crisis, that’s really wrong.

This can only be an intentional misreading of the bill and of reality itself. The PQRI system, for example, provides different codes for a measure. There is usually a code for “did it”, and “didn’t do it because it’s not appropriate” and “didn’t do it because patient doesn’t want to”. The doctor is not in any way pressured to “require” patients to do a damned thing. And if the family changes their mind and “chooses to live”, as McC puts it, there is no reason any sane, non-religious-zealot doctor would stand in the way. While the specific PQRI coding isn’t proposed in the bill, there is not reason “adherence” would stand in the way of “mind-changing”, since then you’ve created a new advanced directive with which to adhere.

I don’t believe that McCaughey is ignorant of these subtleties. I’m not surprised that Stewart didn’t understand the ins and outs of PQRI, as most doctors don’t either, but he got it right when he responded:

That would be really wrong if that was in any way what this really said.

I would add that McCaughey is using her knowledge of the topic to obfuscate, confuse, and deceive. That is what is really wrong.


  1. #1 Rob
    August 21, 2009

    Thanks. I knew there was more to this and was having a hard time finding out what that might be.

  2. #2 Coriolis
    August 22, 2009

    Thanks, great of you to clear that up.

    What’s amusing is that in all this time, this has probably been the most detailed (wonky?) interview I’ve seen on the subject. And it’s by a nominal comedian.

  3. #3 Dave
    August 22, 2009

    Coriolis, both Stewart and Colbert have been hitting them out of the park lately. Even if you disagree with their politics, I would highly recommend making them both staples in your political media diet. And yes, it’s a shame the MSM is shown up by comedians. Crazy world we live in, but consider this:

    “Ridicule is he only weapon which can be used against unintelligible propositions. Ideas must be distinct before reason can act upon them…”
    — Thomas Jefferson

  4. #4 David
    August 22, 2009

    good post Pal. you’re the only blogger I’ve seen who gets the issue.

    a question about the adherence measure: does it apply to all the provider’s patients with A.D.’s or only to those under the provider’s care at the time of death? it seems odd to me to write a PQRI metric that isn’t under the physician’s control.

  5. #5 Gray Gaffer
    August 24, 2009

    I thought the “Adherence” bit meant did the medical community obey the patients’ instructions or not when the EOL time came? Not did the patient adhere to it. In which case, regardless of how many times the patient changed their minds, the instructions current when the time came are all that matter. Perfectly reasonable.

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