American healthcare’s mostly fee-for-service reimbursement model encourages doctors to order tests and procedures so as to make a reasonable living from practicing medicine. There is no incentive to have conversations with patients. Unfortunately, when their patients have to face decisions about what they want to happen (or not happen) as they near death, they need to talk over their options-- not receive a final MRI. When Obamacare was in its formative stage, a provision was introduced that would have required Medicare to pay for a voluntary discussion about advance directives and end-of-life treatment preferences. Geriatricians, palliative care doctors and hospice staffers welcomed this potential statutory provision, but the political opposition for whom the entire Affordable Care Act was anathema went ballistic. They made accusations that this was the precursor to government-sponsored euthanasia, or as Sarah Palin infamously put it, “death panels”.
Seven years of increasing public recognition that end-of-life issues were humane and necessary has recently borne fruit. Now healthcare professionals can punch in a code to bill Medicare for such discussions and receive $80-$85 for a 30-minute “consult” and $75 more for an additional half-hour interchange. Moreover, if the conversation needs to be reopened at a later date, Medicare will again provide compensation. Will this change in Medicare reimbursement solve the problem that only a third or less of patients over 75 and those with debilitating, chronic diseases presently have such interactions?
Certainly, there is little financial incentive, as this level of hourly reimbursement is not going to significantly impact physician income. Moreover, private insurers have not yet followed Medicare’s lead. Most importantly, the significant impediments to success are patient and physician awareness and education. Patients must be informed that these services exist and are available and that they are not tantamount to signing a consent form to withhold all further medical treatment. The documents generated and options chosen must be known to families and available at points of service, not left in drawers and safes. Appointed healthcare proxies must know they have been selected to fulfill their role. On the other side of the conversation, the medical community has not suddenly been endowed with the ability to respectfully broach and explore these very sensitive subjects. These kinds of communications require training and perhaps certification of aptitude.
So will there be a sudden surge in end-of-life discussions? Probably not, but the Federal Government is the elephant in the room and has taken the first step and sent a powerful message about the value of these conversations. Even a journey of a thousand miles requires an initial step.
By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton