The end of life is one of the most difficult topics to broach in conversation among family members and even between patients and their doctors. But the conversations are necessary.
What’s at stake is a person’s ability — to the extent possible — to die according to his or her wishes. Perhaps a family member approaching the end wants to die at home with only enough medical intervention to control the pain. Another might want treatment to put off the end.
But by the time one’s mental capacity is gone and the end is imminent, it’s too late to find out someone’s dying wishes. That’s why it was promising to see Medicare, the health plan for about 15 percent of Americans, on Wednesday take a major step toward encouraging advance care planning — doctor-patient conversations, often including family members, to plan for the end.
If Medicare follows through with its proposal, doctors will be able to bill Medicare for taking the time to sit down with patients and discuss their dying wishes. The results from those conversations are often advance care directives detailing patients’ dying wishes. The patient might make a decision regarding hospice care. He or she might assign powers of attorney for health care decisions to a family member or trusted friend. Doctors have never before been able to collect reimbursement for such conversations. As a result, not enough have happened.
Only about a quarter of U.S. adults have documented their dying wishes. Among people 60 and older, the rate is only about 50 percent.
“The unfortunate result is that often a patient’s illness is extremely advanced by the time the patient and their family seriously consider or prepare for [the end], and physicians with whom they have no prior relationship end up discussing end-of-life care in the emergency department or after admission to the hospital,” a coalition of nearly a dozen medical professional groups wrote in a letter last year calling for reimbursement for advance care planning conversations.
Maine Sen. Susan Collins has long supported the change and is a co-sponsor of legislation that would fund the reimbursement and take other steps to promote advance care planning.
There’s a proven connection between thoughtful advance care conversations and a greater likelihood a patient’s wishes are followed, fewer hospitalizations and less intensive treatments in the final months, and greater use of hospice. Research has also found less stress, anxiety and depression among a patient’s relatives and friends. Other research has even found longer survival among some patients whose advance wishes are followed.
There’s also a financial upside to advance care planning: Medicare saves money by paying for fewer aggressive treatments in the final months of life. That’s a major reason it makes sense for Medicare, which insures about 80 percent of people who die each year in the U.S., to fund advance care planning conversations.
Still, Medicare’s plans are not a done deal.
In 2009, a group of House members from both parties sponsored a provision as part of the Affordable Care Act to have Medicare fund advance care planning. The idea died, however, after Sarah Palin and others characterized the provision as setting up a government-sponsored “death panel.”
The initiative again got caught in the political crossfires two years later when Medicare proposed to follow through with the reimbursement, as it’s proposing now, and the Obama administration backed down.
Medicare last year established billing codes doctors could use to document their use of advance care planning but didn’t fund them. For 2016, the federal government finally plans to attach funding.
For the next two months, the government will accept public comments on the proposal. Medicare should identify specific criteria for advance care planning conversations so it can be sure it’s paying for a high-quality service. And Medicare should consider reimbursing not only doctors, but social workers and other trained counselors who can guide patients through end-of-life planning.
Most of all, it’s important that Medicare and the Obama administration follow through this time. This important step shouldn’t be derailed by politics that reflect our society’s refusal to be honest with ourselves and confront the end of life.
