Detractors of the Affordable Care Act coined the term "death panels" in 2009, effectively creating a death knell for legislation reimbursing providers for advanced care planning.
Five years later, the shadow of that term has waned and the American Medical Association has made recommendations to the nation’s largest insurer—Medicare—to begin paying for end-of-life discussions with patients.
According to the AMA, reimbursing for this service could be highly beneficial for patients and providers alike and could help hospitals reduce costs and improve quality.
"Hospitals are trying to do things that reduce readmissions and provide greater care coordination and are paying a lot of lip service to patient-centered care and this change would align with all of those aspirations," said Mildred Solomon, president and CEO of The Hastings Center, an independent, nonprofit bioethics research institute in Garrison, New York.
Improving care
Solomon said there is an unspoken rule in healthcare now that when a patient comes to the hospital in an acute situation, the team feels responsible for that person to the point of discharge and that is the end of the provider's responsibility. This leaves patients and families without a good path to follow for advanced care.
Most patients want to have these conversations, she said, but they expect their physicians to take the initiative. Many times, however, doctors will not have the discussions, even when it is clear that patients need them.
A study published in 2010 in the Clinical Journal of the American Society of Nephrology found that fewer than 10% of the nearly 600 patients with advanced chronic kidney disease had received some kind of end-of-life counseling from their nephrologist in the past year. A study from 2008 in the Journal of the American Medical Association found that only 37% of advanced cancer patients tracked had been engaged in some kind of end-of-life discussion with their physicians.
And the JAMA study bore out what Solomon said to be true: that these discussions are good for everyone involved. Patients who had these discussions were not more depressed or worried than those who didn't. They had lower rates of ventilation, resuscitation and admission to intensive care. They also enrolled earlier in hospice and had better quality of life scores than patients who didn't talk with their providers about their options.
Providing framework
A handful of states cover advanced care planning for Medicaid patients and some private insurers do so as well. The decision on whether or not Medicare will reimburse for these discussions could be made this fall and it may create a dramatic change in the market.
"It is a very important and necessary step and it will legitimize it and change the social norms to say that it is part of [physicians'] professional responsibility to have these conversations," Solomon said. "It sets a professional standard. It will be part of the job and they will be paid for it."
One thing that will have to be determined is how to reimburse for these talks. According to the New York Times, Blue Cross Blue Shield of Michigan pays providers including doctors, nurses and social workers an average of $35 per conversation in person or by phone. Excellus Blue Cross Blue Shield of New York reimburses doctors $150 for an hour consultation and $350 for two hours.
Solomon said end-of-life discussions should be ongoing and that Medicare should reimburse for more than one visit. Also, that it should be a team approach, so caregivers including nurses and social workers should be eligible for payments.
Hospital executives can create protocols to ensure the conversations are being performed if they are reimbursed for the care. For instance, if a physician sees a patient who they expect could die in the next six months or a year, a process would be set in place to begin discussions.
Not all physicians are comfortable having these discussions, so Solomon recommends providing training by people who are. It could be a very adept physician, a social worker or a hospital chaplain. These people could provide training and could be present for patient visits to participate in the discussions.
"Talk is therapeutic," she said. "Many people want to be reassured that they have control and a plan is in place and no one will abandon them."