The article below (which was originally published by Kaiser Health News (KHN) which is a nonprofit national health policy news service and is being republished under the Creative Commons CC BY 4.0 license) caught my eye and led to a long discussion about end-of-life care between me and Sena, my wife. In fact, I had a link to it in yesterday’s post about retirement. We also had questions about Medicare payments to doctors for having conversations about end of life issues. As a consulting psychiatrist, I sometimes get called by colleagues to assist with questions in this area about challenges addressing it, including but not limited to delirium, depression, and decisional capacity.
I think most people probably are unaware that many state medical boards, including the Iowa Board of Medicine, have mandated End of Life (EOL) Counseling CME activity participation by “primary care physicians” (which includes psychiatrists, at least in Iowa) as a condition of medical license renewal since 2011. I’ve participated and remembered learning about the Physician Orders for Life Sustaining Treatment (POLST) form. One of the activities listed on the Iowa Board of Medicine website, EOL counseling, has been discontinued as of July 31, 2015, but there are alternatives.
I got this sense of irony when I recalled the state medical board mandate for end of life counseling. It can be viewed as a stick (doctors can’t renew their medical licenses if they don’t get the CME) and the new Medicare rule could be viewed as a carrot (doctors get an incentive payment). I’ve seen this carrot and stick approach before with the PQRS:MOC. On the other hand, just because physicians are participating in the end of life CME mandate doesn’t necessarily imply they’re actually having these conversations with their patients.
I also wonder whether this incentive is based on any data showing doctors and patients are not already having these conversations, and whether there is any data showing that having them cuts health care costs at the end of life.
But economic costs are not the only reason, and maybe not really the main reason, for having these discussions. I disagree with the idea that doctors shouldn’t be broaching the issue with their patients and families. In fact, who else but a primary care physician would be in a better position to foster this conversation?
However, what Sena and I noticed, after reading the article below and having probably the longest and most soul-searching discussion we’ve ever had about end of life as it impacts our relationship, was that it makes more sense for families to have their own conversation about it at home, and not necessarily wait for their doctors to bring it up.
I also wondered whether Medicare, by offering this incentive, might be fostering a view of physicians as needing a monetary incentive to discuss end of life issues with their patients and their families. By and large, my experience tells me that most doctors are willing and able to have these discussions and see it as part of their mission as healers (“It is possible to die healed”–Dr. John Shuster) regardless of whether or not a dollar sign is attached to it. And could this payment incentive be part of the reason why some people tend to connect this initiative with the provocative “death panel” bias?
I’m really interested in what other readers think about this.
I could find a lot of versions of this article, all of them indicating that you can post comments about this rule to Medicare, though none specify exactly where or how. In order to save you a lot of time, you can find the document link here and here’s the actual full document with a link to comment in the upper right hand corner (“comment now!” due September 8, 2015). There’s a 282 page pdf if you’re a glutton for punishment. The actual text of the portion of this rule regarding the advance care conversation is below:
C. ADVANCE CARE PLANNING SERVICES
For CY 2015, the CPT Editorial Panel created two new codes describing advance care planning (ACP) services: CPT code 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate); and an add-on CPT code 99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure)). In the CY 2015 PFS final rule with comment period (79 FR 67670-71), we assigned a PFS interim final status indicator of “I” (Not valid for Medicare purposes. Medicare uses another code for the reporting and payment of these services) to CPT codes 99497 and 99498 for CY 2015. We said that we would consider whether to pay for CPT codes 99497 and 99498 after we had the opportunity to go through notice and comment rulemaking.
We received many public comments to the final rule recommending that we recognize these two CPT codes and make separate payment for ACP services, in view of the time required to furnish the services and their importance for the quality of care and treatment of the patient. For CY 2016, we are proposing to assign CPT codes 99497 and 99498 PFS status indicator “A,” which is defined as: “Active code. These codes are separately payable under the PFS. There will be RVUs for codes with this status.” The presence of an “A” indicator does not mean that Medicare has made a national coverage determination regarding the service. Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy. We are proposing to adopt the RUC-recommended values (work RVUs, time, and direct PE inputs) for CPT codes 99497 and 99498 beginning in CY 2016 and will consider all public comments that we receive on this proposal.
Physicians’ services are covered and paid by Medicare in accordance with section 1862(a)(1)(A) of the Act. Therefore, CPT code 99497 (and CPT code 99498 when applicable) should be reported when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury. For example, this could occur in conjunction with the management or treatment of a patient’s current condition, such as a 68 year old male with heart failure and diabetes on multiple medications seen by his physician for the evaluation and management of these two diseases, including adjusting medications as appropriate. In addition to discussing the patient’s short-term treatment options, the patient expresses interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient’s desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However, the ACP service as described in this example would not necessarily have to occur on the same day as the E/M service.
We seek comment on this proposal, including whether payment is needed and what type of incentives this proposal creates. In addition, we seek comment on whether payment for advance care planning is appropriate in other circumstances such as an optional element, at the beneficiary’s discretion, of the annual wellness visit (AWV) under section 1861(hhh)(2)(G) of the Act.
Remember the so-called death panels?
When Congress debated the Affordable Care Act in 2009, the legislation originally included a provision that would have allowed Medicare to reimburse doctors when they meet with patients to talk about end-of-life care.
But then Sarah Palin argued that such payments would lead to care being withheld from the elderly and disabled. Her comment ignited a firestorm among conservatives and helped fuel the opposition to the legislation.
Her assertions greatly distressed Dr. Pamelyn Close, a palliative care specialist in Los Angeles.
“It did terrible damage to the concept of having this conversation,” she said.
Amid the ensuing political uproar, Congress deleted the provision. And the lack of payments and concerns about the controversy further discouraged doctors from initiating these talks, according to Close.
“We just are not having these conversations often enough and soon enough,” Close said. “Loved ones who are trying to do always the right thing, end up being weighed with tremendous guilt and tremendous uncertainty without having had that conversation.”
When done right, according to Close, these counseling sessions often delve into end-of-life treatment options and legal documents, such as advance directives and living wills. The issues to be covered are complex and typically require a series of discussions.
Right now, Medicare only pays doctors for this sort of advanced care planning if it happens during the first visit for new Medicare enrollees. But the government recently has again proposed that Medicare reimburse doctors for including these conversations in their practice, whenever they occur.
Already, some private insurance companies are starting to do just that.
Meanwhile, the Alliance Defending Freedom, a conservative Christian organization, has formally opposed Medicare’s proposal.
“By paying doctors for these conversations, what we’re doing is opening the door to directive counseling and coercion,” said Catherine Glenn Foster, an attorney with the group. Foster says her organization supports end-of-life counseling and planning, but not in a doctor’s office.
“A doctor is not really the person you’d want to be having it with – particularly not a general practitioner who would not be able to advise on the nuances of end-of-life care in the first place,” she says.
But patients seem to want these talks. A 2012 study by the California HealthCare Foundation found that 80 percent of Californians would like to have an end-of-life conversation with their physician, but fewer than one in 10 has done so.
Many doctors who initiate the discussions often do so on their own dime. More often, they don’t have them at all, said Dr. Daniel Stone, an internist with Cedars-Sinai Medical Center in Los Angeles.
“When a doctor has patients scheduled every 15 minutes, it’s difficult to have a face-to-face conversation about values and goals related to the end of life, which is one of the most sensitive topics that you can possibly discuss with a patient,” Stone said.
Dr. Susan Tolle, an internist with the Center for Ethics in Health Care at the Oregon Health and Science University in Portland, says the informality with which such conversations are held now means that family members may not be included. Having the discussion as part of a formal doctor’s appointment can change that, she said.
“What it does is, it gives this really important conversation dignity and standing,” she said.
In Oregon, doctors have been squeezing end-of-life discussions into regular medical appointments for decades, under less-than-ideal circumstances. Over the last five years a quarter of a million Oregonians filed their wishes with a state registry. They use what’s known as a POLST form, which stands for Physician Orders for Life Sustaining Treatment. A version of it has been adopted by some other states, including New York and West Virginia.
Jo Ann Farwell, a retired Portland social worker who was recently diagnosed with a brain tumor, completed the form after talking to her doctor.
“I had surgery and had a prognosis of four to six months to live,” she said, after she was diagnosed with a brain tumor.
She did it, she said, to make sure her last hours are as comfortable as possible.
“I wouldn’t want to be on tube-feeding,” she said. “I wouldn’t want to be resuscitated, or have mechanical ventilation, because that would probably prolong my dying, rather than giving me quality of life.”
In the 1990s, health care workers all over Oregon recognized that the wishes of patients weren’t being consistently followed. So the health care establishment worked with the state and with ethicists to prioritize end-of-life talks; the result was the POLST form.
Rep. Earl Blumenauer, a Democrat from Portland, has introduced the Medicare reimbursement legislation every session since 2009. Until now, he says, the federal government hasn’t placed any value on helping people prepare for death, and he finds that ironic.
“The Medicare program will pay for literally thousands of medical procedures, many of them very expensive and complex, even if the person is at the latest stage of life and it may not do any good,” Blumenauer says.
From a purely financial point of view, the change could save money. But Blumenauer says that’s not what’s driving him.
“I don’t care what people decide,” he says. “If they want to die in an ICU with tubes up their nose, that’s their choice. What we want is that people know what their choices are.”
Farwell, the brain tumor patient, well remembers when her sister was dying from cancer.
“She never talked about death or dying,” Farwell said, “never talked about what she wanted at the end. It was very, very difficult for me to try to plan and give her care.”
Farwell wants her sons to be in a better position when it comes to carrying out her wishes.
The federal government is now accepting public comment on the Medicare reimbursement proposal. It’s expected to make a decision in November.
This story is part of a partnership that includes KPCC, Oregon Public Broadcasting, NPR and Kaiser Health News.
KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.