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.
Agreed. We should be ale to die on our terms.
Double agreed!
The difference is that Medicare will now pay Docs for these discussions. The affluent don’t need that incentive: they have the advance directives etc. This will help poorer people take control of their lives and deaths. next we need Death with Dignity passed in more states.
I have worked as an RN Case Manager for decades.
I have case managed for health care insurances and case managed every imaginable hospital unit, the last ICU’s in the largest hospital in our state. I attended numerous conferences regarding end of life and did a lot of research. I consulted with palliative staff and intensivists frequently.
It amazed me how many patients had never had a conversation about their end of life.
When I retired I took a position that gave me the opportunity to do community outreach in assisting people come to terms with end of life. We held forums, we made home visits, met with families and residents in nursing homes, worked with the Alzheimer’s Association, home care agencies, and social service agencies. This was a passion and many people were appreciative, relieved, liberated.
I was fortunate enough to work with one the best palliative teams in my last hospital of employment. I only wish more people would have the opportunity to meet with them and hear about services that are available.
In addition to Medicare paying for end of life discussions, they, and insurances have got to start improving reimbursement for palliative services. Every human being deserves to be able to obtain comfort on many levels. People deserve to have choices. They deserve the opportunity to meet with professionals to learn options…and those discussions need to be reimbursed.
Hi Jane the RN.
Great insight and thank you for your dedication and many years of work in the field of healthcare.
End-of-life planning needs to be understood as less about how you want to die, and more about your wishes of what medical professionals should do to your body when you are not able to make decisions for yourself. This respects patient autonomy–the opposite of decision making by a panel. I work in a hospital. On a daily basis I see the children of patients having to make sudden, agonizing decisions based on what they think their parent would have wanted. It often divides family members at a time they need to be supporting each other. Advanced care planning between a patient, when they are healthy and able to clearly process information, and their trusted physician of choice on their personal wishes regarding matters such as life support, painfully breaking ribs during CPR, or tube feedings when there is not hope for recovery is an individualized decision. Having a documented plan brings dignity to the end of life process, lifts unnecessary stress from families, and will save our nation billions of dollars a year in futile care. This is long overdue. Let’s hope that the cable talk show hounds and politicians do not hijack this conversation with deliberate misinformation–again!!
This is actually pretty much the same provision that created the huge
outcry in 2009 when it was added by Republicans to the Affordable Care
Act”
End of life care is a sensitive issue. Many patients are reluctant to initiate that discussion with their doctor. But we as health care providers are morally obligated to be proactive & ask our patients the hard questions. Failure to attend to this issue denies our patients the dignity that every person surely deserves.
End of life care is a sensitive issue. Many patients are reluctant to initiate that discussion with their doctor. But we as physicians are morally obligated to be proactive & ask our patients the hard questions. Failure to attend to this issue denies our patients the dignity that every person surely deserves. It’s about time that insurance providers recognize these realities & fulfill their moral obligation by paying providers something for the time spent on such discussions. It is disgusting that politicians like Palin seek to politicize other people’s personal struggles with medical illness. Anyone who wants to get the government out of people’s private lives must endorse unrestricted end of life discussions.