CMS wants to pay doctors to talk about end-of-life care planning

Decision follows 'death panel' controversy six years ago

Get the Advisory Board's expert take on this story.

CMS on Wednesday proposed that Medicare reimburse providers for having advance care planning conversations with patients.

The proposal was included in CMS's proposed rule for the calendar year 2016 Medicare Physician Fee Schedule (PFS). CMS is accepting public comment on the proposed rule through September 8. (See our related story in today's Daily Briefing for how Medicare's proposal will affect physicians.)

The issue of end-of-life care came up during the debate over the Affordable Care Act in 2009, but opponents of the overhaul mischaracterized a provision that would have reimbursed physicians for end-of-life care consultations as "death panels." The provision ultimately was left out of the final reform law.

Details of advance care planning proposal

Under the new PFS proposal, Medicare would reimburse qualified providers—including doctors, physicians, and nurse practitioners—for in-person meetings with patients and their relatives or caregivers to discuss patients' wishes if they become too ill to voice their own decisions on their end-of-life medical care.

The proposal would not limit the number of such conversations Medicare would cover. "The reality is these conversations, their length can vary based on patients' needs," says Patrick Conway, the CMO of CMS. The agency views advance care planning discussions as "an important part of patient- and family-centered care," Conway explains.

CMS is seeking comment on whether Medicare should cover advance care planning discussions as part of individuals' annual wellness exams. Reimbursement rates for the counseling sessions and other details will be decided following the public comment period, according to Conway.

The advance care planning proposal is expected to be included in the final version of the physician fee schedule, Pam Belluck reports for the New York Times. If adopted, the proposal would take effect on January 1, 2016.

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Implications of proposal

According to the Associated Press, the proposal would open up such coverage to 55 million Medicare beneficiaries. Medicare beneficiaries account for about 80% of U.S. residents who die each year, making the program the "largest insurer at end of life," according to the Kaiser Family Foundation.

Further, private insurers often look to Medicare to set coverage standards, which means more private health plans could offer such coverage.

Reaction

Several advocacy organizations have expressed support for Medicare's proposal.

Advanced care planning has "been mischaracterized in the past, and it is time to facilitate patient choices" on the issue, says American Medical Association President-elect Andrew Gurman.

American Academy of Family Physicians President Robert Wergin says that advance care planning "is a vital part of medical care that merits compensation, and we look forward to working with CMS to ensure inclusion in the physician fee schedule."

However, a handful of groups have come out against the proposal. The National Right to Life Committee (NRLC) argues the proposal it could cause patients to be pressured into rejecting "lifesaving medical treatment." NRLC is pushing for legislation that would direct Medicare to develop materials regarding end-of-life counseling reflecting various viewpoints, including those "concerned with protecting people's right to treatment" (Belluck, New York Times, 7/8; Robeznieks/Dickson, Modern Healthcare, 7/8 [subscription required]; Sedensky/Alonso-Zaldivar, AP/San Diego Union-Tribune, 7/8; Armour/Radnofsky, Wall Street Journal, 7/8).

The Advisory Board's take

Harrison Brown, Post-Acute Care Collaborative

This payment is a great step toward giving patients the care they want and need during the toughest of times. Advance care planning ensures patients' wishes are voiced, documented, and respected, but packed physician schedules and tight reimbursement have historically left these lengthy discussions overlooked.

But, while this proposal strengthens the incentive to create and update advance care plans, we still have a long way to go on this issue.

Many providers lack the comfort and training to make these conversations meaningful. Moreover, few health systems have the information infrastructure to ensure all providers have access to the patients’ most up-to-date wishes.

Ultimately, we will need to pair these payments with investments in education and information management if we are going to tackle this issue well.

Hear more from Harrison

View this webcoference featuring findings from interviews with advanced illness experts in both creating and disseminating consumer resources for navigating advanced illness. Learn:

  • A dual-population framework for building a resource dissemination strategy
  • Best practices for distributing system-wide resources such as advanced directive toolkits
  • Best practices for implementing resources to assist with goals of care conversations

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