DUNDEE, N.Y. -- Five years after it exploded into a political conflagration over "death panels," the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions might be covered for the 50 million Americans on Medicare as early as next year.
Bypassing the political process, private insurers have begun reimbursing doctors for these "advance care planning" conversations as interest in them rises along with the number of aging Americans. People are living longer with illnesses, and many want more input into how they will spend their final days, including whether they want to die at home or in the hospital. Some states, including Colorado and Oregon, recently began covering the sessions for Medicaid patients.
But far more significant, Medicare may begin covering end-of-life discussions next year if it approves a recent request from the American Medical Association, the country's largest association of physicians and medical students. One of the association's roles is to create billing codes for medical services, codes used by doctors, hospitals and insurers. It recently created codes for end-of-life conversations and submitted them to Medicare.
The Centers for Medicare and Medicaid Services, which runs Medicare, would not discuss whether it will agree to cover end-of-life discussions; its decision is expected this fall. But the agency often adopts the association's recommendations, which are developed in meetings attended by its representatives. And the political environment is less toxic than it was when the "death panel" label was coined. Though there are still opponents, there are more proponents, including Republican politicians.
If Medicare adopts the change, its decision would also set the standard for private insurers, encouraging many more doctors to engage in these conversations.
"We think it's really important to incentivize this kind of care," said Dr. Barbara Levy, chairman of the American Medical Association committee that submits reimbursement recommendations to Medicare. "The idea is to make sure patients and their families understand the consequences, the pros and cons and options so they can make the best decision for them."
Some doctors conduct such conversations for free or shoehorn them into other medical visits. Dr. Joseph Hinterberger, a family physician in Dundee, N.Y., wants to avoid situations in which he has had to make decisions for incapacitated patients who have no family or stated preferences.
Recently, he spent an unreimbursed hour with Mary Pat Pennell, a retired community college dean, walking through advance directive forms. Pennell, 80, who sold her blueberry farm and lives with a roommate and four cats, said she would not want to be resuscitated if her heart or lungs stopped. But she took longer to weigh options regarding if she was breathing but otherwise unresponsive.
"I'd like to be as comfortable as I can possibly be," she said.
With reimbursement, "I'd do one of these a day," said Hinterberger, whose 3,000 patients in the Finger Lakes region include college professors and Mennonite farmers who tie horse-and-buggies to his parking lot's hitching post.
If Medicare covers end-of-life counseling, that could profoundly affect the American way of dying, experts said. But the effect would depend on how much doctors are paid, the allowed frequency of conversations, whether psychologists or other nonphysicians could conduct them, and whether the conversations must be in person or could include phone calls with long-distance family members. Paying for only one session and completion of advance directives would have limited value, experts said.
"This notion that somehow a single conversation and the completion of a document is really an important intervention to the outcome of care is, I think, a legal illusion," said Dr. Diane Meier, director of the Center to Advance Palliative Care. "It has to be a series of recurring conversations over years."
End-of-life planning remains contentious. After Sarah Palin's "death panel" label killed efforts to include it in the Patient Protection and Affordable Care Act in 2009, Medicare added it to a 2010 regulation, allowing the federal program to cover "voluntary advance care planning" in annual wellness visits. But bowing to political pressure, President Barack Obama's administration had Medicare rescind that portion of the regulation. In doing so, Medicare wrote that it had not considered the viewpoints of congressmen and others who opposed it.
Politically, the issue was dead. But private insurers, often encouraged by doctors, began taking steps.
"We are seeing more insurers who are reimbursing for these important conversations," said Susan Pisano, a spokesman for America's Health Insurance Plans, a trade association.
This year, for example, Blue Cross Blue Shield of Michigan began paying an average of $35 per conversation, face-to-face or by phone, conducted by doctors, nurses, social workers and others.
Cambia Health Solutions, which covers 2.2 million patients in Oregon, Washington, Idaho and Utah, started a program including end-of-life conversations and training in conducting them.
Excellus Blue Cross Blue Shield of New York does something similar, and its medical director, Dr. Patricia Bomba, has spearheaded the development of New York's advance directive system. Doctors can be reimbursed $150 for an hour-long conversation to complete the form, and $350 for two hours.
End-of-life planning has also resurfaced in Congress. Two recent bipartisan bills would have Medicare cover such conversations, and a third, introduced by Sen. Tom Coburn, R-Okla., would pay Medicare patients for completing advance directives.
But few people think the bills can pass.
"The politics are tough," said Dr. Phillip Rodgers, co-chairman of public policy for the American Academy of Hospice and Palliative Medicine. "People are so careful about getting anywhere close to the idea that somebody might be denying lifesaving care."
It is unclear whether advance care planning saves money. But some studies suggest that it reduces hospitalizations because many people prefer to die at home or in hospices, so cost-saving can be an inadvertent result, said Dr. William McDade, president of the Illinois State Medical Society, which asked the American Medical Association to create codes for the discussions.
The conversations do not lock people into decisions, and studies show that some change their minds in a crisis.
But evidence suggests that discussions can make a difference. One study found that cancer patients who previously discussed end-of-life preferences with doctors more often received care matching those wishes. Other studies suggest planning lowers stress in patients and families.
Reimbursement rates for talking are much lower than for medical procedures. But doctors say that without compensation, there is pressure to keep appointments short to squeeze in more patients.
"Not to be crass about this, you're just giving that service away," Rodgers said.
A Section on 08/31/2014