The Washington Cartel


Why I haven’t seen this video before, and why it has not gone viral, is beyond me.  Listening to this speech, I feel as relieved as I did listening to Reagan in the late 1970s explaining calmly and clearly to the American people how we were being hoodwinked by politicians who promised to protect us if only we would send them more money, more power, more steps toward socialized medicine.

Senator Cruz describes, in plain language, the machinations of what he terms “the Washington Cartel” of K Street lobbyists and politicians. (The speech lasts about 40 minutes, but keep listening for his superb answer to why we might expect him to keep his word).  It’s easy to see why establishment Republicans — and Donald Trump, by the way — might not want you to hear this.

Incidentally, he mentions insurance companies.  Insurance companies are the tip of the iceberg.  We know that hospitals and professional organizations and others are in on the game too.  And the game isn’t only about greed, as the consumerists would have you believe.  Often the objective is ideological — the misguided desire to fundamentally transform society; to take a health care system that is malfunctioning largely because of government meddling, and try to “fix it” with more meddling.

Here are a few of my picks for the Washington Cartel Hall of Fame:

Please listen to Cruz’s speech, and share it with a friend.

A step beyond food fascism

Are “culture of health” and “culture of death” mutually exclusive?  Ask most refugees from 1930s socialist Europe, and my guess is their answer will not only be “no,” but more likely “the former ushers in the latter.”  That is to say, it is difficult to imagine a culture that assigns a value on human beings based upon their health, without questioning what that culture does to human beings who are judged to be “not healthy.”

What brings this question to mind is a disturbing quotation, in large bold-face type, found at the National Academy of Medicine website. The Academy is announcing its new Culture of Health program funded by the Robert Wood Johnson Foundation (RWJF), and it explicitly links a person’s social value to being well:

A culture of health is where good health flourishes across geographic, demographic, and social sectors; where being healthy and staying healthy is an esteemed social value; and where everyone has access to affordable, quality health care. [emphasis added]   — Risa J. Lavizzo-Mourey, President & CEO, Robert Wood Johnson Foundation

Millions of frail, elderly, disabled people are chronically ill due to no fault of their own. Will they be esteemed in this new Culture of Health?

Over at the RWJF website, the foundation is asking their partners to help them visualize this brave new world:

We’ve listened as [educators, policymakers, business leaders, community organizers] have told us how they are picturing themselves living in a Culture of Health.

Let me help out with that picture.  No elderly, sick, wheelchair-bound “super-utilizers.” Only young, athletic, vibrant persons.  Only the fit?  Something like this:

Religion in a Post-Constitutional America

As one of my favorite authors has noted, we are in a post-Constitutional America. One example is the much-discussed and controversial Proposed Rule from CMS to incentivize end-of-life conversations.

Here’s another pathetic example.

Last month the Department of Health and Human Services, drawing on Executive Order 13559, took upon itself the responsibility of further micro-managing faith-based organizations via Proposed Rule ACF_FRDOC_0001-0058, “Updating Participation in Programs by Faith-Based or Religious Organizations and Providing for Equal Treatment of Program Participants.”

Among other things, the Proposed Rule distinguishes “inherently religious activities” from “explicitly religious activities”:

The Department [HHS], therefore, proposes to replace the term “inherently religious activities” with the term “explicitly religious activities” throughout the Equal Treatment Regulations and to define the latter term as “including activities that involve overt religious content such as worship, religious instruction, or proselytization.” These changes in language are consistent with the use of the term “explicitly religious activities” in Executive Order 13559 and will provide greater clarity and more closely match constitutional standards as they have been developed in case law.

To read the entire rule, and perhaps learn what type of activities you might be engaged in, visit Regulations.gov (a bureaucrat’s dream come true).

The public is invited to comment – blog style – through October 5, 2015. Click here to submit your comments to the regulating entities.

“Death Facilitators Being Sneaked in over Labor Day Weekend”

Once again the administration is trying to push through by fiat — with a few new twists — what Congress and the American public have already rejected.

Not only is the government offering an incentive to physicians (and presumably the hospitals and clinics and nursing homes  that hire them) to have “end-of-life” conversations with their sickest patients, but there is question as to which other “qualified professionals” might be be paid to introduce end-of-life discussions to patients.

Although CMS is required to receive comments from the public on this controversial measure, mysteriously the online comment form has not gotten much publicity. Commenting will close on Tuesday night.

The following press release from the Association of American Physicians and Surgeons broke the story yesterday:

TUCSON, Ariz., Sept. 4, 2015 /PRNewswire-USNewswire/ — The deadline for comments on a key method for facilitating early death is Tuesday just after Labor Day weekend. Buried in 250 pages of changes to the CPT procedural codes required to claim Medicare payment are two new ones, 99497 and 99498. These pay for end-of-life discussions with physicians or other “qualified professionals.”

Such discussions often culminate in POLST—Physician Orders for Life-Sustaining Treatment. They are supposed to reflect the patient’s “choices” for what is to be done, or not done, in the event of an illness or accident.

The “qualified professional” in Advance Care Planning may be a “facilitator” whose training was funded by the Affordable Care Act, using a curriculum such as Respecting Choices®.

The creation of these special codes was promoted by the National POLST Paradigm Task Force. The electronic medical record will help identify who has or has not completed a standardized form.

Patients need to understand that “life-sustaining treatment” includes food and water. “Artificially administered nutrition and hydration” may be by intravenous or feeding tube, which may be given (or withheld) even though the patient is potentially able to eat or drink but is temporarily unable to do so—perhaps because of heavy sedation.

Physicians may be pressured to meet a quota for POLST forms and to conform to government-prescribed standards for an “acceptable” conversation. The existence of a form may make it impossible for physicians or family members to override the pre-written orders agreed to in a scripted session with a facilitator, even if the attending physician believes there is a prospect of recovery, AAPS warns.

Ensuring an early demise is an effective way to achieve the stated goal of reducing healthcare costs. And the well-funded, expansive “palliative care” movement has been working for decades to promote euthanasia by another name, observes AAPS.

Elizabeth Wickham of LifeTree.org points out that the Obama Administration withdrew earlier, similar regulations in 2011 after a New York Times article called attention to it.

“The ‘death panels’ have come back from the dead with news that the Centers for Medicare and Medicaid Services (CMS) is going to pay for ‘end of life counseling’ for Medicare beneficiaries as a separate service. What this really means is they are pushing these conversations by adding a financial carrot,” states AAPS president Richard Amerling, M.D.

Comments may be submitted until 5 p.m. Eastern time, Sept 8.

Bernard Shaw — Poster boy for shared decision-making?

Bernard Shaw, euthanasia and death panel advocate, remarked:  You must all know half a dozen people at least who are no use in this world, who are more trouble than they are worth. Just put them there and say Sir, or Madam, now will you be kind enough to justify your existence?"

Bernard Shaw, euthanasia and death panel advocate:  “You must all know half a dozen people at least who are no use in this world, who are more trouble than they are worth. Just put them there and say Sir, or Madam, now will you be kind enough to justify your existence?”

How perfect.  Bernard Shaw as the spokesman for decision aids for terminally ill patients.

I’m sure the irony was lost on the author of “The Judges Have Spoken: Decision Aid Upgrade Design Challenge Winners Announced” as she opened her story with a quotation from Shaw.

The article announced the winners of a contest sponsored by California HealthCare Foundation (CHCF) to develop new tools to coach cancer patients and their families in treatment decisions.  Not surprisingly, the shared decision-making tool that won first prize from CHCF coaches the patient toward palliative care.

This particular tool is for cancer, where diagnosis is generally straightforward and prognosis is very often well-defined. Tools can be trickier, and perhaps more misleading, for patients with other conditions.

Decision aids are all the rage now.  As I reported two years ago, the masterminds at Center for American Progress and others involved in transforming our health care system are looking to “shared decision-making” tools to save money by cutting so-called unnecessary treatments, persuade patients and families to decline life-saving treatments, and at the same time to create the illusion that patients are making decisions for themselves.

So it is ironic that Jennifer David of Health 2.0, announcing the CHCF prize, quotes Bernard Shaw: “The single biggest problem in communication is the illusion that it has taken place.”

Bernard Shaw, beloved of the progressives, was a great believer in eugenics, and a member of the Voluntary Euthanasia Legalization Society.  No doubt he would have admired so-called decision aids, and other projects funded by the California HealthCare Foundation — projects designed to cut spending on so-called futile care, and to create the illusion that patients are in control.

Government-subsidized end-of-life conversations . . . What could possibly go wrong with that?

Thanks to Mark Levin for his plain-language critique last week of the proposed CMS payment codes for (endless) end-of-life conversations. Levin speaks for many elderly, sick and vulnerable patients and their families who are being pressured into “letting go,” and this even without government-paid end-of-life talks.

Thanks, also, to Right Scoop for posting the audio, so that it gets the attention it deserves.

Levin read portions of the New York Times story [Medicare Plans to Pay Doctors for Counseling on End of Life, 7/8/2015] breaking it down and cutting through the propaganda as he went along.

I’ll link to the audio here; an unofficial transcript is posted below.  (Audio for the entire 7/9/2015 program is available to download free at http://www.marklevinshow.com/audio-rewind/ )

TRANSCRIPTION BY BELBURY REVIEW:

Mark Levin:  This is the biggest story of the day; just like yesterday the biggest story was — not the Confederate flag — …the biggest story yesterday was Obama nationalizing zoning so that he could destroy the suburbs in the country. And nothing happens. Not even a peep. Where’s Boehner? Boehner’s looking for signs of the Confederacy on Capitol Hill…”

Listen to this story and see how screwed up our news media are; see how screwed up our priorities are …

[New York Times:] Medicare …which insures 55 million older and disabled Americans, announced plans on Wednesday to reimburse doctors for conversations with patients about whether and how they would want to be kept alive if they became too sick to speak for themselves.

This is a family matter, ladies and gentlemen; families have these discussions. Children with their parents. Not the federal government paying doctors and nurses to have this discussion, so they can just wipe them off the Medicare rolls. And trust me they are going to pressure hospitals to do this stuff, and doctors and nurses to do this stuff. They’re already pressuring people to push them out the door. Let’s continue:

The proposal would settle a debate that raged before the passage of the Affordable Care Act, when Sarah Palin labeled a similar plan as tantamount to setting up “death panels” that could cut off care for the sick. The new plan is expected to be approved and to take effect in January, although it will be open to public comment for 60 days.

This is the game …”we have a 60-day public comment.” Public comment on what?!  98% of the public doesn’t even know what’s going on, and it’s not their fault. Federal government shouldn’t even be involved in these things, and the government is involved in everything. Let’s continue:

Medicare’s plan comes as many patients, families and health providers are pushing to give people greater say about how they die — whether that means trying every possible medical option to stay alive or discontinuing life support for those who do not want to be sustained by ventilators and feeding tubes.

That’s not what this is. This is the government pushing to say that you don’t want to be kept alive. They want those beds empty. They want to move you out. And it’s happening right now. I know people in their 80s and 90s, they’re having this done to them. Trying to push them out, push them out, at the direction of the federal government. Here’s the Chief Medical Officer for the Centers for Medicare and Medicaid, Patrick Conway:

“We think that today’s proposal supports individuals and families who wish to have the opportunity to discuss advance care planning with their physician and care team,”… “We think those discussions are an important part of patient- and family-centered care.”

Oh it sounds so swell, and wholesome. “This is family-centered care.” … it’s not family-centered care. It’s get the [heck] out of the hospital.

Conway said a final decision on the proposal would be made by Nov. 1. The plan would allow qualified professionals like nurse practitioners and physician assistants, as well as doctors, to be reimbursed for face-to-face meetings with a patient and any relatives or caregivers the patient wants to include. Dr. Conway said the proposal did not limit the number of conversations reimbursed.

That is, pressure; pressure! You have an 80-year-old, 90, 95-year old father or mother or grandparent; you’re trying to get them the best care you can, which is very, very difficult in Obama’s America; you already have the hospitals pressing you to “Well, you know… ” Have you had this conversation if you have an elderly parent or grandparent? “Well, you know, they are 90″ or “well you know, they are 87; they’ve lived a full life…” Have you had that [happen]?  I’ve heard this. Is that the kind of conversation they’re getting paid to have?

““The reality is these conversations, their length can vary based on patients’ needs,” he said. “Sometimes, they’re short conversations — the person has thought about it. Sometimes, they’re a much longer conversation. Sometimes, they’re a series of conversations.”

Now, Medicare has a zillion codes … code after code; thousands of codes. Thousands. And now they’re going to add codes for end-of-life discussions. End of life. “How many have you had … You’ll get reimbursed for how many you had.  You had ten? Okay. What was the outcome?”

What was the outcome.

You never thought you’d live to see this day, did you?

This is the New York Times, now, making the case for the federal government…

. . . Major medical organizations endorsed Medicare’s proposal. The National Right to Life Committee opposed it on grounds that it could lead to patients’ being pressured to forgo treatment.

Of course! That’s the whole purpose! Why have a discussion otherwise? Because the default position is to keep the person alive; to talk to the family: “well, what do you want to do?”  Well, keep them alive!  “Let’s have some conversations! (for which we’re reimbursed.)”

The reimbursement rate paid under the proposal and other details will be determined after public comments are received, …. People covered by Medicare account for about 80 percent of deaths each year.

It’s just not enough! You old people aren’t dying fast enough! Why do you keep hanging on?

Because Medicare often sets the standard for private insurers as well, the new policy would prompt many more doctors to engage patients in such discussions about their preferences.

Let’s just look at this. So, if they’re having discussions with the patients, that means that the patients are not senile; they don’t have Alzheimer’s or dementia of some form, right? That means they’re competent enough to have a discussion.

And they’re lying there in the hospital, on their back, maybe on a respirator, who knows!, maybe not. They’re trying to get better, maybe they had this conversation with their family, and the nurse and the doctor are paid to say “You know what, Charlie, look, you’re 89, you’re 89; I’m not saying anything’s going to happen to you, but you’re 89.  Maybe you have a 10% chance of walking out of here, Charlie; what do you want to do?”

Now that person, that 89-year-old, 87-year-old, 91-year-old, 73-year-old, whomever, whatever, should be focused on getting better, trying to keep their spirits up. Even if it is their last days! They don’t need to talk to a stranger about “end of life options.” Funded by Medicare.

And of course it will never be abused. They don’t abuse people at the VA, or the IRS, or the EPA. No no no; never. Every federal employee is good-hearted, noble and virtuous. Every doctor and nurse, good-hearted noble and virtuous. Let’s continue.

Efforts to support end-of-life planning were derailed in 2009 during the debate over [Obamacare]. The next year, Medicare decided through its regulatory powers to allow coverage for “voluntary advance care planning” in annual wellness visits.

Annual Wellness Visits? So the person isn’t necessarily even in the hospital and they want to have a conversation about how they end their life. Or whether they end their life. And this is supposed to be health care. This is supposed to be medical care. Do you want your government doing this?

But soon after, the Obama administration capitulated to political pressure and rescinded that part of the regulation. . . .
As a big part of the American population ages, and more people live longer with grave illnesses, a growing number of people want to be able to talk over options with their doctors —

So, fine! What does that have to do with the government encouraging, through Medicare, doctors and nurses to have that discussion? If somebody wants to have the discussion, well, have the discussion.

. . . about whether they want to die at home or in the hospital, or under what circumstances they would want life-sustaining treatment.

I want to tell you what’s going on here. Not only does Medicare want to cut costs by cutting benefits to the people they’re supposed to be supporting — senior citizens, and the sickest among them; the most elderly among them — but it wants to come between the family and the patient. There is no reason for a doctor or a nurse to be affirmatively raising these issues, and to be PAID, be subsidized, to raise these issues. That’s what families do.

Burke Balch, the director of the National Right to Life Committee’s Powell Center for Medical Ethics, said his organization objected to Medicare’s plan under current circumstances. “We feel there is pervasive bias against treatment that is occurring in advance care planning that involves nudging individuals to reject lifesaving medical treatment.”

He’s exactly right. Otherwise why would the government do this?

And by the way, I don’t want to hear any more about how compassionate the left is; how compassionate Medicare is; how compassionate the federal government is. The only reason this regulation is going to happen is because they want to cut costs, and they want to cut off the breathing tube to senior citizens. There’s no other reason to have it. And they want to come between children and their parents. That’s what they’re doing. Shouldn’t this be issue number one today, all over the country?

END OF TRANSCRIPT.

 

Former White House health policy advisor: Get the public on board

In case you missed it, this was Chris Dawe last year, shortly after he left the Obama administration, and before he joined Evolent Health — a consulting company founded by the Advisory Board and the Univ. of Pittsburgh Health Plan “to help health systems move towards providing value-based care.”  (Advisory Board, which consults for C-TAC, was founded by David Bradley, now Chairman of Atlantic Media.)

Here Dawe is addressing the Campaign to End Unwanted Medical Treatment (which is in fact a campaign to gin up the public to demand less life-saving treatment.  Talk about perverse.)

Dawe expresses his admiration for Donald Berwick; says Berwick’s tenure was all too short.

Late in the video (46:50) Dawe fields a question from Compassion & Choices CPO Mickey MacIntyre about educating patients on death trajectories, “soft landings” and end of life choices (some of which education will happen via PCORI), but ends up saying the public needs to be educated about what’s coming when “this starts to get serious” and CMS mandates a new model of care (ACOs for example) — “that’s something that really disrupts the status quo and that’s when [he trails off – but implies that’s when people will start complaining]. “There are many potential losers here; not everyone can win when health care costs come down.”

Near the end of the video Dawe chuckles at the mention of IPAB, and explains that SGR legislation will do some of what IPAB was supposed to do.

And of course he couldn’t leave the podium without a final whine about Sarah Palin.

Distinction without a difference? Guidance from the NCBC

Last month the National Catholic Bioethics Center posted an article that was meant to guide Catholic clinicians on what to do when a patient or proxy or government requests treatment that the clinician considers to be morally wrong [“Transfer of Care vs. Referral: A Crucial Moral Distinction”]

The subject is important and timely, and I looked forward to reading the piece, but unfortunately it misses the mark when it comes to issues where withholding/withdrawing treatment and palliative care would be involved.

1) The first few paragraphs imply that the immoral act in question might be an act of withholding/withdrawing treatment, so I expected the authors to give advice to the poor clinician who is being pressured to withdraw life-saving treatment. Instead, the authors write three paragraphs to reassure the clinician that “no treatment at all” can be a “reasonable and morally legitimate alternative” and “should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.” (They don’t elaborate on what might be “contrary to Catholic moral teaching”). So while the authors pretend to be concerned about a patient’s right to life-saving treatment, they are really more concerned about justifying withdrawal of treatment.

This discussion might have been relevant thirty years ago, but in the new world of accountable care organizations, where the physician will be held accountable for what group will get which “scarce resources,” the concern about the patient’s right to “no treatment at all” is passé.

2) The fine distinction between “formal cooperation” and “material cooperation” escapes me, but I gather that “material cooperation” is a bit like double effect: it hinges on the intent of the cooperator. That gives the cooperator a little wiggle room.

3) There seems to be an underlying assumption that if the patient is transferred to “ethical palliative care” (usually meant in a hospice or end-of-life sense) then all is well. Even if, miraculously, thousands of “ethical palliative care” practices sprang up all over the country overnight, what would a referral to an “ethical palliative care” practice mean in the context of the new continuum of care established by the Accountable Care Act and regulatory agencies?

Who will be referred to palliative care in this new normal? A report released yesterday by C-TAC provides a new diagram of where palliative care fits in “the continuum of care.”

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C-TAC’s illustration of palliative care’s role in the “continuum of care”

The diagram illustrates how far we have wandered from the palliative care associated with hospice and end-of-life. Palliative care is now supposedly the care of choice for most of the population:

(That’s a pretty lucrative market.)

The Clinical Practice Guidelines for Quality Palliative Care identify a very broad group of palliative care prospects, some of whom we might not want to subject to repeated end-of-life conversations, or to subtle shifting away from ordinary care: families of neonates with “developmental and intellectual disabilities” who develop serious illness; as well as “vulnerable, underserved, and under-resourced populations who develop serious or life-threatening illness….” (my emphasis).  When the Guidelines were first introduced, one of the people involved in their development wrote that the role of the guidelines was to facilitate “good healthcare [which] requires continual re-appraisal of useful and non-beneficial therapies….”  She went on to list populations that would be targeted. First on the list: “Children and adults with congenital injuries or conditions leading to dependence on life-sustaining treatments.”

When “the system” (electronic health records, case managers, Medicare/Medicaid, government regulation, The Joint Commission) dictates that a patient be referred or transferred to palliative care consultation at the first diagnosis of what “the system” considers a “chronic condition”, how will the Catholic palliative care team handle the referral? Will the palliative care group accept the patient, even though the team is reasonably certain that end-of-life care will not be needed for many years to come? How far will the palliative care group be willing to go to combat “the system” that will try to convince the patient and/or family to remove life-sustaining treatment prematurely? Will they go to bat for the patient/family, or meekly hand off the patient to another group?

All in all, I felt as though I was reading an article that had been written thirty years ago.  The principles are timeless; but when it comes to the issue of withholding/withdrawing treatment, the standard examples are irrelevant if not misleading.

Compassion & Choices is funding the American Society on Aging blog

Just a quick nota bene that the current edition of Generations — the journal for the American Society on Aging (ASA) — is posted on ASA’s blog courtesy of funding from Compassion & Choices (the present incarnation of the old Hemlock Society) and the Robert Wood Johnson Foundation.

One of the articles is by AARP veteran and Coalition to Transform Advanced Care (C-TAC) co-founder Bill Novelli (“Advanced Illness Care: We Can Do Better“).

Novelli and his friends at C-TAC still haven’t gotten over the fact that they met resistance (which was bipartisan, by the way) when in 2009-2010 their friends in Congress and the White House tried to sneak through legislation and regulation requiring end-of-life planning.  Novelli can’t stand open and honest debate; it is “toxic”:

During the passage of health reform a few years ago, political controversies surrounding the language and messaging of advance care planning led to misguided notions regarding government panels and end-of-life care decisions. This turned the debate into one that was toxic, strikingly partisan, and devoid of rational, open discussion.

And Novelli repeats the standard (unsettling) refrain that all these sick old people are costing us money:

In 2010, more than a third of Medicare beneficiaries experienced four or more chronic conditions. Those with four to five conditions cost $12,174 in per capita spending, and those with six or more chronic conditions averaged nearly $32,658 in per capita spending (Centers for Medicare & Medicaid Services [CMS], 2012).

C-TAC recommends more hospice, more advance care planning, and more research to provide the “metrics” they need to more accurately redefine “quality”:

CMS can work closely with well-established private-sector entities, such as the National Quality Forum, to develop consensus on key quality metrics to be adopted by Medicare to assess the quality of care delivered at the end of life (including measures that include quality, cost, access, and patient and family satisfaction).

. . . The systemized collection and reporting of quality measures are essential to building the evidence base for effective interventions . .  and driving effective payment and delivery reform. The passage of the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) in October 2014  . . . will allow Medicare to compare quality performance across settings, improve discharge planning, and use this data to guide and inform future payment and delivery reform efforts.

 

University of Geneva invites Ezekiel Emanuel to make the case for dying at age 75

Ezekiel Emanuel is taking his I-Hope-To-Die-at-75 road show to Switzerland at the invitation of the University of Geneva, where he will be speaking today.

In an interview with Le Temps, Emanuel emphasized that he is opposed to euthanasia and assisted suicide:  [translation from French with the help of Google Translate]

I am opposed to euthanasia and assisted suicide. I feel that people who want that recourse mainly suffer from depression and fear of losing their dignity; we must first provide them with care and compassion. I will not put an end to my life intentionally. But I will not try to prolong it either! From age 75, I will accept neither predictive tests nor care – except for palliative care that reduces pain. I’ll do no more cardiac tests. I will not take more antibiotics and I will not be vaccinated against the flu. If I have cancer, I will refuse any treatment.

He would make a great poster child for the Choosing Wisely campaign against “unnecessary medical care.”

Emanuel was fairly blunt.  Though he doesn’t advocate limiting lives to age 75, he does feel that the state (which is paying for health care, thanks to health planners such as Dr. Emanuel) should not be concerned if life expectancy falls; that the state should focus on young people:

. . . I think that developed countries should stop focusing on the life expectancy of their populations. It is useless to chase after Japan, Monaco and Macau, which are the countries where people die the oldest. Once a life expectancy of 75 years or more is reached, the state should stop worrying about that. Efforts could then specifically focus on the health of the youth and the disadvantaged groups – such as African American men who have a lower life expectancy than whites.  A massive investment in research into Alzheimer’s disease also seems to me indispensable.

I wonder what sort of research he wants on Alzheimer’s patients, and what he hopes to get from it.  Not longer lives, no doubt.