Medicare, the federal program that insures 55 million older and disabled Americans, announced plans recently to reimburse doctors for conversations with patients about whether and how they would want to be kept alive if they became too sick to speak for themselves.
The proposal would settle a debate that raged before the passage of the Affordable Care Act, where opponents labeled a similar plan as tantamount to setting up “death panels” that could cut off care for the sick. The new plan is expected to be approved and to take effect in January, 2016 although it will be open to public comment for 60 days.
Medicare’s plan comes as many patients, families and health providers are pushing to give people greater say about how they die — whether that means trying every possible medical option to stay alive or discontinuing life support for those who do not want to be sustained by ventilators, feeding tubes and other life supporting devices.
“We think that today’s proposal supports individuals and families who wish to have the opportunity to discuss advance care planning with their physician and care team,” said Dr. Patrick Conway, the chief medical officer for the Centers for Medicare and Medicaid, which administers Medicare. “We think those discussions are an important part of patient- and family-centered care.”
Dr. Conway said a final decision on the proposal would be made by Nov. 1. The plan would allow qualified professionals like nurse practitioners and physician assistants, as well as doctors, to be reimbursed for face-to-face meetings with a patient and any relatives or caregivers the patient wants to include. Dr. Conway said the proposal did not limit the number of conversations reimbursed.
“The reality is these conversations, their length can vary based on patients’ needs,” he said. “Sometimes, they’re short conversations — the person has thought about it. Sometimes, they’re a much longer conversation. Sometimes, they’re a series of conversations.”
Major medical organizations endorsed Medicare’s proposal. The National Right to Life Committee opposed it on grounds that it could lead to patients’ being pressured to forgo treatment.
The reimbursement rate paid under the proposal and other details will be determined after public comments are received, Dr. Conway said. People covered by Medicare account for about 80 percent of deaths each year.
Because Medicare often sets the standard for private insurers as well, the new policy would prompt many more doctors to engage patients in such discussions about their preferences. Some private health insurance companies have recently begun covering such advance care planning conversations, and more are likely to do so once Medicare formally adopts its new rules.
As a big part of the American population ages, and more people live longer with grave illnesses, a growing number of people want to be able to talk over options with their doctors — deciding, for example, whether they want to die at home or in the hospital, or under what circumstances they would want life-sustaining treatment.
Such programs may start to reduce the widely recognized problem of overly aggressive medical treatment, and attendant suffering, near the end of life. Studies have found that about a third of Medicare patients have surgery in their last year of life, and 17 percent die in an intensive care unit or shortly after a stay. Too many families have cursed, in hindsight, the false hopes, unheld conversations and rushed medical decisions that led them there.
In the hour of our deaths, most of us will yearn not to cut short our time but opt for a “soft technology” of compassion, caring and interpersonal skill. We will want to give someone our last words and final blessings. We will probably hope to have someone we love at our side, to be forgiven for things we regret and to be remembered. To truly die with dignity, we will need good nursing, practical support, pain management and kindness. All should be better reimbursed by Medicare.