Tuesday, July 21, 2015

Putting to Rest the “Death Panel” Lie

Earlier this month, Medicare issued a proposal to begin paying physicians for the time and work involved in engaging their patients in advance care planning.  If finalized by the agency, the new benefit will be available to physicians and their Medicare patients starting in 2016.

It’s about time!  For many years now, ACP has championed advance care planning and has urged Medicare and other insurers to cover it.  As articulated in our Ethics Manual, “Advance care planning allows a person with decision-making capacity to develop and indicate preferences for care and choose a surrogate to act on his or her behalf in the event that he or she cannot make health care decisions. It allows the patient's values and circumstances to shape the plan with specific arrangements to ensure implementation of the plan. Physicians should routinely raise advance planning with adult patients with decision-making capacity and encourage them to review their values and preferences with their surrogates and family members. This is often best done in the outpatient setting before an acute crisis.”

Yet when Medicare in 2010 offered to include voluntary advance care planning in the new Medicare wellness exam, it unleashed a fury of criticism that if the government reimbursed doctors for discussing advance care planning with their patients, physicians would then pressure patients to give up on treatment and end their lives—the notorious “death panel” lie about Obamacare.  Because of the partisan backlash, Medicare ended up withdrawing the proposal.

That was then, this is now.  Today, the idea that Medicare should reimburse doctors for advance care planning has bipartisan support.  Even before Medicare issued its new proposed rule, U.S Senators Johnny Isakson, R-Ga., and Mark R. Warner, D-Va., had introduced legislation designed “to give people with serious illness the freedom to make more informed choices about their care, and the power to have those choices honored” by “creating a Medicare benefit for patient-centered care planning for people with serious illness.”

Now that members of both political parties agree on the wisdom of empowering patients to take control of their own healthcare, perhaps this will also mark the time when the notorious “death panel” falsehood is put to rest, once and for all.

Today’s question: what do you think of Medicare’s proposal to pay for advance care planning?


Jay Larson MD said...

Every year for their wellness exam our patients are questioned about advanced directives. If they don't have one, it is discussed and an advanced directive is given to them to fill it out. Most people have it on their "to do" list but have never gotten around to doing it. The problem with Medicare paying for an advanced care discussion is that the reimbursement is going to be too low. Saying a service is covered does not equate to a service being appropriately paid for.

DrJHO7 said...

I have been having conversations with my patients about advance care planning/advance directive, including living wills, acute rescussitation or "code status", POA, etc., for 25 years. I have not done it "for free," as was alluded in the NYT article. I have done this in the space of time of the office visit, included in the time based component for the visit if I chose to document and bill it that way. I have had more of these discussions this year, admittedly since the documentation of such will be an important domain for submission of PQRS data to CMS for 2015, via a registry I participate in. When you dedicate x number of minutes to such conversation, you either bump something else from the agenda of discussion and examination, or you take extra time (that wasn't scheduled) and get further behind in your schedule.

Each discussion with each patient/ and-or family present is unique to the needs of that patient, based on their ability to communicate, their level of health literacy, various questions and explanation.
It may involve producing copies of blank living will documents or other literature, and may involve a broader discussion of one's medical condition and prognosis.
case in point: the business of "acp" (advance care planning) is highly variable re: work and time, but clearly takes both. So, it's a nice concept that CMS is "finally" recognizing the value of this exercise and planning to "pay" physicians for this work.

Having tried some of CMS' other recent efforts to provide reimbursement for other laudable efforts of physicians (smoking cessation, obesity counseling, the "screening prostate exam" and the chronic care management codes), I conclude with disappointment that no good turn on my part will go unpunished. The documentation requirements for such exercises are complex, burdensome, time-consuming, and in and of themselves, inadequately reimbursed, let alone the work that the physician performs on the task itself. Then there is the issue of scheduling. Patients don't come in for their "acp" session. They have their own agenda of what is bothering them, and that is their primary concern.

So, I'm not excited about the new "coverage." I'll probably try billing it a few times and see how it goes, unless the documentation requirements are ridiculous like they usually are. If such is the case, I'll do what I do now, and make it part of the usual medical care I provide, properly prioritized and integrated into the other aspects of the patient's care, customized to their needs.

Maybe patient-centered practices will have non-physician personnel attend to "acp" discussions and other such tasks so everyone is working at the top of their license. If that were the case, physicians might never have to do this work (but you could still bill for it, right?). What a shame. Sometimes this is the most important discussion a physician may ever have with their patient, with significant impact on their care experience and their outcome.

PCP said...

I think this issue should never have been politicised. Of course one can count on a politician to meddle where he/she does not belong ie in that doctor-patient relationship. A doctors time is his/her commodity, and a personal physician is the person patients trust most to have that conversation with. That this time should be compensated fairly is without serious argument. Personally there are a thousand other things I'd rather do with the time rather than do this specifically. However I think this is an important piece in the holistic care of a patient as they enter their golden years. It is also a way by which that PCP relationship is nurtured. That it might save costs should never have even been mentioned. Even if it doesn't it would still be the right approach.