Lisa Vaden of the Hospice & Palliative Care Association of Arkansas said patients would benefit from advance care planning.
By the time most doctors talk to terminally ill patients about end-of-life care, it’s already too late.
“The patient can’t even make a decision for themselves,” Dr. Sarah Beth Harrington, medical director of the Palliative Care Program at the University of Arkansas for Medical Sciences, told Arkansas Business last week. “And we have to go to the surrogate decision-makers — the families — and say, ‘What would the patient want if they could talk to us?’”
That conversation with family members “is highly, highly stressful … if there’s no road map or advanced directive,” Harrington said.
But the Centers for Medicare & Medicaid Services hopes to change that. On July 8, CMS proposed paying doctors for their time spent talking with Medicare patients about end-of-life planning. The proposed rule will be open for public comment through Sept. 8. A ruling is expected Nov. 1. If approved, the payment system would take effect Jan. 1.
The plan to pay doctors to talk with patients about end-of-life care generated controversy in 2009 when it was set for inclusion in the Patient Protection & Affordable Care Act, also known as Obamacare. The proposal, added to the bill by a Republican, was scrapped when it was mischaracterized as creating “death panels.”
Although doctors and health care workers broadly support the payment proposal, some people are concerned that elderly people will be guided toward giving up on medical care, leading to a premature death.
“We think it’s a very bad idea to use federal tax dollars to finance” the talks about end-of-life planning, said Burke Balch, the director of the Robert Powell Center for Medical Ethics at the National Right to Life Committee of Washington. The group claims to be the nation’s oldest and largest grassroots antiabortion organization.
“There’s not only a very strong financial motivation to try to nudge people to reject expensive treatments, but also the information that is routinely provided is not only unbalanced but often is distorted and even factually inaccurate,” Balch said.
Patients with chronic illnesses in their last two years of life account for about 32 percent of total Medicare spending, with much of that going for doctors and hospital fees tied to repeated hospitalizations, according to The Dartmouth Atlas of Health Care of Lebanon, New Hampshire, which is supported by several groups, including the Robert Wood Johnson Foundation.
Balch said the National Right to Life Committee plans to fight the proposal.
Several health care organizations, however, welcome CMS’ proposal.
“The support for this from the medical community has been overwhelming because the folks who do this work every day understand that it’s necessary,” said Dr. Phil Rodgers, a co-chair of the American Academy of Hospice & Palliative Medicine’s Public Policy Committee.
Allowing the payment will help doctors and patients develop a road map for how to deal with terminal illnesses.
“This is really a good, important step in improving care for Medicare beneficiaries with a serious, potentially life-limiting illness,” said Harrington, of the Palliative Care Program.
If payment for the consultation time is approved by Medicare, the federal health insurance program primarily for people aged 65 and older, then she expects private insurance companies would follow CMS’ lead.
Currently, doctors aren’t reimbursed for time spent speaking to Medicare patients about end-of-life care. If the conversation takes place at all, it usually happens when it’s too late to consider all of a patient’s options, said Lisa Vaden, the executive director of the Hospice & Palliative Care Association of Arkansas, a nonprofit organization that promotes access to hospice care.
“This is about anyone facing a serious illness [having] appropriate time to spend with their physician for care planning,” Vaden said. “It might explain to them more treatment or care options that they weren’t even aware of.”
The American Medical Association also supports the payment policy.
“The proposed Medicare payment rule affirms the need to support conversations between patients and physicians to establish and communicate the patient’s wishes in responding to various medical situations,” Dr. Andrew W. Gurman, president-elect of the American Medical Association, said in a news release last month. “This issue has been mischaracterized in the past and it is time to facilitate patient choices about advance care planning decisions.”
Death Panels
In the summer of 2009 in the midst of the health care reform discussions, former Gov. Sarah Palin of Alaska criticized overhauling health care, charging it would lead to health care rationing, according to an Aug. 13, 2009, article in The New York Times.
“The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care,” Palin said. “Such a system is downright evil.”
The comments about “death panels” spread and damaged the chances of getting the doctors paid for their consultations with patients, said Harrington.
“The whole ‘death panel’ thing — it was just a bunch of nonsense,” she said. “It wasn’t based on any kind of fact.”
Talking to Patients
Harrington said most doctors aren’t talking to their patients about end-of-life care. But among those who are, she said, the conversations are coming too late.
“It’s better than before,” she said. “It’s getting better every year that more physicians are comfortable and more patients are asking to have these conversations.”
Harrington said doctors would need more training on how to talk to patients about how they want their treatment to proceed.
“In the medical school curriculum there is more emphasis on communication,” she said. “There’s been a lot of improvement, but we still have a ways to go.”
Rodgers, of the AAHPM, said he understands the concerns of groups like the National Right to Life Committee. But he said doctors aren’t coming in with a patient’s treatment schedule.
“We approach advance care planning as having us understand what’s most important to the patient and family, so we can get them the best care possible,” he said. “We don’t come to these conversations with any agenda.”
Rodgers said the conversation about end-of-life care should occur at the time of the detection of the serious illness. He said the plans developed should be flexible and updated with changes in health status.
Rodgers said the talk shouldn’t be a quick conversation either.
Harrington said if patients decide they would rather spend their final days at home than tethered to machines in an intensive care unit, it would save health care dollars.
“It’s a nice side effect that it costs less,” she said. “But that’s not the purpose of having advance care planning. … Most patients want to be at home.”
A 2007 Duke University report in the medical journal Social Science & Medicine found Medicare spends an average of $24,000 during the last year of a beneficiary’s life. The study also reported that hospice care reduced a Medicare beneficiary’s expenses by an average of $2,309.
Most doctors would prefer to die at home, according to the 2011 essay “How Doctors Die” by Dr. Ken Murray, a retired clinical assistant professor of family medicine at the University of Southern California. And nearly 90 percent of doctors would rather decline lifesaving measures if they had a terminal illness, according to a May 2014 study by Stanford University Medical School.
Harrington said if a patient has a terminal illness, getting a bunch of tests or procedures probably isn’t going to do much to extend the life.
“It’s very telling that most physicians say when they’re at the end of life, they’d rather be home,” she said. “They don’t want to be in the hospital.”
Sign up for Daily E-news
