Are
Doctor’s Really Getting Paid For
“
End-Of-Life” Care
Talks
With Their Patient’s?
SHOULDN’T
THIS BE PART OF CARING FOR YOUR PATIENT AND NOT AN EXTRA CHARGE?
 |
| Dr. Joseph Hinterberger discussed end-of-life care with Mary Ann Zebrowski. If reimbursed, “I’d do one of these a day,” he said. Credit Heather Ainsworth for The New York Times |
Coverage for End-of-Life Talks Gaining Ground
AUG.
30, 2014
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
may 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, and whether they want full-fledged
life-sustaining treatment, just pain relief or something in between.
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 A.M.A.’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
A.M.A. 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;
although there are still opponents, there are more proponents, including Republican
politicians.
If Medicare adopts
the change, its decision will 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, chairwoman of the A.M.A. 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.”
Now, some doctors conduct such conversations for free
or shoehorn them into other medical visits. Dr. Joseph Hinterberger, a family
physician here in Dundee, wants to avoid situations in which he has had to
decide for incapacitated patients who had 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. Ms. Pennell, 80, who sold her blueberry farm and lives with a roommate
and four cats, quickly said she would not want to be resuscitated if her heart
or lungs stopped. But she took longer to weigh options if she was breathing but
otherwise unresponsive.
“I’d like to be as comfortable as I can possibly be,” she
said at first. “I don’t want to choke, and I don’t want to throw up.”
With reimbursement,
“I’d do one of these a day,” said Dr. Hinterberger,
whose 3,000 patients in the Finger Lakes region range from
college professors to 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 impact would
depend on how much doctors were 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 E. 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 controversial. After Sarah
Palin’s “death panel” label killed efforts to include it in the 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, the Obama
administration had Medicare rescind that portion of the regulation.
In doing so, Medicare wrote that it had not considered the viewpoints of
members of Congress 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 spokeswoman for America’s Health
Insurance Plans, a trade association. The industry, which usually uses Medicare
billing codes, had created its own code under a system that allows that if
Medicare does not have one, and more insurance companies are using it or
covering the discussions in other ways.
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. And Cambia Health
Solutions, which covers 2.2 million patients in Idaho, Oregon, Utah and
Washington, started a program including end-of-life conversations and training
in conducting them.
Doctors
can be reimbursed $150 for an hour long conversation to complete the form, and
$350 for two hours.
Dr. Hinterberger learned of Excellus’s coverage when he
called recently to ask about end-of-life discussions, but even if he undergoes
Excellus’s training to qualify for reimbursement, most of his older patients
have only Medicare.
End-of-life planning has also resurfaced in Congress. Two
recent bipartisan bills would have Medicare cover such conversations, and a
third, introduced by Senator Tom Coburn, Republican of Oklahoma, 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.”
Burke Balch, director of the Powell Center for Medical
Ethics at the National Right to Life Committee, said in a statement that many
doctors believed in “hastening death for those deemed to have a ‘poor quality
of life.’ ” If Medicare covers advance care planning, he said, that plus
cost-saving motivations will pressure patients “to reject life-preserving
treatment.”
Doctors deny that.
“Honestly, sometimes I’m making an argument that treatment
is not as bad as you think because of our ability to mitigate side effects,”
said Dr. Thomas Gribbin, a Grand Rapids, Mich., oncologist who recently
persuaded two Michigan insurers to cover end-of-life conversations.
It is unclear if advance care planning saves money, but
some studies suggest that it reduces hospitalizations. 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 A.M.A. 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,” Dr. Rodgers said.
Recently, Dr. Hinterberger took time from other patients
and his duties at Schuyler Hospital in Montour Falls, N.Y., to conduct
end-of-life conversations in his frank, casual style.
He told Ms. Pennell that if she experienced severe
pneumonia or a serious accident, doctors might consider putting her on a
ventilator or inserting a feeding tube. She could stipulate that she wanted
only pain relief, essentially instructing doctors to “just kiss me and tell me
you love me,” he said. Or she could ask for short-term interventions in case
“you perk back up.” Or she could indicate, “I want everything.
Just do it, do it,” he said.
Video: Obama speaks in the background about his Health Care plan as Mr. Roth
visits the government's euthansia clinic for some "End of Life
Counseling" and ultimately some "green" recycling ...
“The middle option,” she eventually decided.
When Janice Ryan, 89, a former protective services worker
with a bone marrow disorder, said she wanted nothing “unless I can recover and
feel wonderful,” Dr. Hinterberger gently suggested allowing doctors to try.
“Give the doc some options,” said her husband, Dick, a
retired professor. She agreed, but added, “I want quality of life; I don’t want
to just be a vegetable.”
Dr. Hinterberger spent 40 minutes with Helen Hurley, 83,
whose lung disease requires her to use nasal tubes connected to an oxygen tank
she carries in a flowered bag. Then she tired, asking to finish the discussion
in future visits, “a little at a time.”
But Mary Ann Zebrowski, 75, a retired vineyard worker with
diabetes and arrhythmia, had a lot to say. She described her husband’s collapse
in 2008, saying she was glad he had been resuscitated, but felt pressured to
agree to a feeding tube because a doctor said, “What are you trying to do, kill
your husband?” She eventually decided to remove the tube and let him die.
