End of Life

Medicare Plans to Pay Doctors for Counseling on End of Life

By PAM BELLUCK

Medicare, the federal program that insures 55 million older and disabled Americans, announced plans on Wednesday 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, when Sarah Palin 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, 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 and feeding tubes.

“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.

Efforts to support end-of-life planning were derailed in 2009 during the debate over the Affordable Care Act. The next year, Medicare decided through its regulatory powers to allow coverage for “voluntary advance care planning” in annual wellness visits. But soon after, the Obama administration capitulated to political pressure and rescinded that part of the regulation.

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.

Last September, a national nonpartisan panel of medical, legal and religious leaders issued a far-reaching report saying that the country’s system for dealing with end-of-life care was seriously flawed and should be overhauled. Among its recommendations was that insurers reimburse health providers for advance care planning conversations.

Filling out advance directives can help, and some states have created central databases of these forms so they are easier for a patient’s doctor or specialist to find in moments of crisis. But end-of-life experts, and the members of the national panel, said simply checking boxes on a form was of limited value because many patients needed several conversations to consider their options and to talk them over with their families.

“It’s a huge step forward,” said Dr. Diane Meier, a member of the national panel and the director of the Center to Advance Palliative Care. “I think it’s great news that Medicare, the major payer for health care in the U.S., is now formally recognizing that advance care planning is worthy of its attention and reimbursement and that in fact is a way to restore power and control to patients.”

But, she said, “It’s not enough to pay for it. You have to make sure people know what they’re doing and are well trained.”

Dr. Meier said that in the final policy, Medicare should identify and require documentation of specific components of end-of-life discussions. “What you don’t want to have is a check-box,” she said. “ ‘Yes I had a conversation — I’m billing for it,’ should not be enough.”

Burke Balch, the director of the National Right to Life Committee’s Powell Center for Medical Ethics, said his organization objected to Medicare’s plan under current circumstances. “We feel there is pervasive bias against treatment that is occurring in advance care planning that involves nudging individuals to reject lifesaving medical treatment,” he said. He said such pressure on patients was “motivated in large part by a desire to cut health care costs.”

Mr. Balch said his organization was trying to find a congressional sponsor for a bill that would instead direct Medicare to produce materials about end-of-life decisions that reflect a range of views, including those “concerned with protecting people’s right to treatment.”

In the rural upstate New York community of Dundee, Dr. Joseph Hinterberger, a family physician who has been conducting end-of-life discussions with his patients at no cost, took a different view. He praised several aspects of the plan and suggested also covering social workers and other trained providers.

“I think what it will mostly do is decrease confusion at the end of life,” he said. “It will potentially decrease unnecessary use of resources because it will be very clear what the patient did and did not want. And it should also make it easier for physicians and other caregivers to make decisions because they can say, ‘We all know what Mildred’s wishes were. We shall not tread upon them.’ ”