Many medical providers, end of life care activists and hospice nurses support Medicare reimbursement for end of life conversations between physicians and patients.
Medicare could soon begin reimbursing doctors if proposed billing codes from the American Medical Association are approved. Almost five years ago, similar proposals were dropped from the Affordable Care Act amid allegations that coverage for end of life conversations would lead to “death panels.”
“Each year, the AMA provides CMS with revisions to the CPT (Current Procedural Terminology) coding system that is used to price thousands of physician services. In a typical year, there are hundreds of codes that are either new, revised or deleted,” according to a CMS statement sent to Life Matters Media.
The Centers for Medicare and Medicaid Services may choose to establish payment and cover the sessions as described by the code; not pay for the specific code, but cover the sessions as part of another code; or deny payment altogether. A decision is expected this fall.
Sessions for some 50 million Americans could be covered by Medicare, and some private insurers have already started reimbursing doctors for time spent helping patients complete advance health care directives. Interest in doctor-patient communication has increased as baby boomers age.
“We think it’s really important to incentivize this kind of care,” Dr. Barbara Levy, chair of the AMA committee that sends codes to CMS, told The New York Times. “The idea is to make sure patients and their families understand the consequences, the pros and cons and options so they can make the best decision for them.”
The hope is that doctors will encourage more seriously ill patients to complete advance health care directives and identify “goals of care.” An advance directive may take the form of a living will, power of attorney or the Five Wishes collection. The overall purpose of such forms is to help ensure one’s end of life wishes are carried through in case of illness or incapacity.
“Just as important as the completion of these documents are the discussions that patients have with their physicians and other health care providers, as well as their family members,” said Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization, in a statement to Life Matters Media. “Discussing advance care planning before a person finds him or herself in a medical crisis will help ensure the patient is more likely to get the care that he or she wants.”
Research shows patients that discuss their care options when facing a serious or life-limiting illness report a higher quality of life. “Family caregivers also benefit from discussions held between physicians and patients,” Schumacher added.
When health care reform was signed into law in 2010, many Democrats wary of being identified with “death panels” dropped all proposals associated with end of life planning, despite support from many in medicine.
According to Politifact, a Pulitzer Prize-winning fact checker, comparing end of life counseling to “death panels” was 2009′s “Lie of the Year.” Former vice presidential candidate and Alaska governor Sarah Palin was the first to coin the term “death panels” on her Facebook page after the release of an early draft of the bill. Some conservatives charged that vital care would be cut off to the aged and ill if doctors recommended they receive less aggressive treatments.
Karen N. Long, president of the Chicago End-of-Life Care Coalition, said she believes many oppose coverage for end of life discussions out of ignorance.
“Everyone in this field has been working on this for a long time. It’s very much needed, because it helps patients think about what’s important to them, what they consider a ‘good’ quality-of-life,” Long told LMM. “I think most of the controversy goes back to the conflated issue of ‘death panels,’ where some individuals misquoted and misunderstood what was in the proposed law.”
Dr. June M. McKoy, director of geriatric oncology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, described coverage for end of life counseling as a “double edged sword,” because physicians must be careful not force their medical advice or religious and political beliefs upon patients.
“Doctors do not live in a vacuum,” she told LMM. “Can doctors learn not to be paternalistic? To also be quiet and listen? To be a facilitator?”
McKoy recommends doctors develop a trusting relationship with their patients and bring up end of life-related discussions more than once, because a patient’s wishes can change.
She called the “death panels” controversy “farfetched and ludicrous,” because most medical centers have “layers” to protect patients, and that most doctors work to honor their patients’ wishes.
“Coverage can be a great thing, because it gets the conversation going. Many people don’t get the chance to make their own end of life decisions — somebody else makes it for them. It helps to have decisions in writing,” she added. “It helps families, too. I have seen families torn terribly apart after a parent dies, when siblings stop talking to each other, because they disagree about the parent’s medical care.”
Loretta Downs, a hospice volunteer and end of life care activist, supports coverage for end of life counseling because she fears receiving unwanted treatments in case of incapacity.
“I just turned 65, and Medicare is spending a great deal of money on various medical tests that are triggered by turning 65,” she told LMM. “It would be helpful and practical to include payment for a conversation with my primary care physician about protecting me from unwanted medical treatment if I unexpectedly became hospitalized in critical condition and unable to voice my choices for treatment.”