Six years ago, a group of U.S. House members from both parties sought to encourage more patient-doctor conversations focused on planning for care toward the end of life. The representatives tried to include a provision in the Affordable Care Act to have Medicare, for the first time, reimburse doctors specifically for those advance care planning conversations.
An outcry over the effort, including Sarah Palin’s declaration that the provision was tantamount to the federal government setting up death panels, derailed it, and the Affordable Care Act became law without the provision.
On Friday, Medicare — the health plan for about 15 percent of Americans — followed through with a rule change proposal it unveiled this summer to reimburse doctors for advance care planning conversations. Starting Jan. 1, the Centers for Medicare and Medicaid Services announced, doctors will be able to bill Medicare for up to 60 minutes of such conversations with each patient.
The negative reaction this time was muted compared with 2009. In Congress, there’s one bill pending to stop the reimbursements. Sponsored by Rep. Steve King, R-Iowa, the legislation hasn’t gained much traction. It’s been pending before a House subcommittee since the end of July and has attracted only three co-sponsors.
Medicare’s move to reimburse end-of-life planning conversations is important and welcome. There’s a proven benefit to patients and their families from having their end-of-life wishes documented, then followed by medical personnel. Thoughtful advance care conversations often lead to fewer hospitalizations, less intensive treatments in the final months and greater use of hospice. The existence of an end-of-life plan can reduce anxiety and depression among relatives and friends, other research has found.
There’s also no denying the financial upside for Medicare from more advance care planning: Medicare, which insures about 80 percent of people who die each year in the U.S., saves money by paying for fewer aggressive treatments in the final months of life.
But advance care planning happens too seldom. Only about a quarter of U.S. adults have documented their dying wishes through use of legally binding living wills or advance care directives. 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.
Now that they can receive reimbursement for it from Medicare, doctors and the health care systems they work for will have to make end-of-life planning a routine part of medicine. In medical school, doctors-to-be should more commonly receive training so they can effectively broach the end of life in those all-important conversations with patients. Social workers, counselors and other trained facilitators will have to be available to help people complete advance care directives.
There’s legislation pending in the Senate — Maine Sen. Susan Collins has signed on as a co-sponsor — that would help with some of those next steps, including a push for public education about advance care directives.
Reimbursing doctors for end-of-life planning conversations is an important part of encouraging a greater portion of the population to document their end-of-life wishes. But it’s only the start.
