Group Proposes Strengthening Medicare Plan to Pay Docs for End-of-Life Care Conversations
Conversations Should Start Early, Take Place At Least Once a Year on As Needed Basis
(Washington, DC – Sept. 4, 2015) Compassion & Choices today suggested two ways to improve a proposal by the Centers for Medicare & Medicaid Services (CMS) to reimburse doctors for communicating with patients about whether and how they would want to be kept alive if they become too sick to speak for themselves.
Compassion & Choices offered the following recommendations to strengthen the CMS proposal:
- The initial conversation about a patient’s healthcare treatment preferences should take place during the “Welcome to Medicare” preventive visit to ensure an early start to these conversations, before the diagnosis of a terminal illness.
- CMS should give physicians the flexibility and autonomy to engage in additional conversations as needed. Ideally, these conversations should take place at least once a year as a part of a patient’s annual medical review. However, the patient and physician should be given the autonomy to engage in these conversations as needed. For example, they may need additional conversations based on a patient’s disease diagnosis, prognosis and trajectory.
The suggestions are in response to a Sept. 8 deadline to submit comments to the Federal Register about a July 8 proposal to make advance care planning a separate payable service under Medicare codes 99497 and 99498 starting in 2016.
“Funding these two Medicare advance planning codes removes a barrier for doctors to initiate and engage in conversations that ensure healthcare providers honor patients’ treatment goals, preferences and values,” wrote Kimberly Callinan, Chief Program Officer for Compassion & Choices, a national end-of-life choice advocacy organization. “We encourage CMS to enact this regulation, provide the necessary funding, and continue to look for and address other potential barriers to these critically important discussions between patients and healthcare professionals.”
“These conversations can help patients understand their treatment options, recognize the need to plan ahead for the care they choose, avoid unwanted medical treatment and better ensure their end-of-life healthcare wishes are carried out if they are unable to speak for themselves,” Callinan concluded. “Evidence-based research overwhelmingly shows the need for more and higher-quality doctor-patient conversations about the patient’s healthcare goals, preferences and values.”
The evidence-based research supporting the CMS proposal includes:
- According to a Sept. 2014 report by the Institute of Medicine (IOM), “Dying in America, Improving Quality and Honoring Individual Preferences Near the End of Life”: “Most people nearing the end of life are not physically, mentally, or cognitively able to make their own decisions about care. Approximately 40 percent of adult medical inpatients, 44-69 percent of nursing home residents, and 70 percent of older adults facing treatment decisions are incapable of making those decisions themselves. The majority of these patients will receive acute hospital care from physicians who do not know them. As a result, advance care planning is essential to ensure that patients receive care reflecting their values, goals, and preferences” (Kim et al., 2002; Nelson et al., 2006; Raymont et al., 2004; Silveira et al., 2010).
- The IOM reports’ “Key Findings and Recommendations” includes: “Frequent clinician–patient conversations about end-of-life care values, goals, and preferences are necessary to avoid unwanted treatment. However, most people—particularly younger, poorer, minority, and less-educated individuals, do not have these conversations. Clinicians need to initiate conversations about end-of-life care choices and work to ensure that patient and family decision making is based on adequate information and understanding.”
- The Journal of the American Medical Association (JAMA) published an article in December 2014, “Communication about serious illness care goals: a review and synthesis of best practices” that concluded: “An understanding of patients’ care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of non-beneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress.”
- According to a study published in the January 2014 edition of The American Journal of Preventive Medicine, “Completion of Advance Directives Among U.S. Consumers” only one out of four Americans (26%) have completed an advance directive to ensure their end-of-life healthcare wishes are carried out if they are unable to speak for themselves.