Sunday, August 31, 2014

Why pay for end-of-life conversations?

A story by Pam Belluck in the New York Times left me with mixed feelings.  Here's an excerpt:

Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans. Some states, including Colorado and Oregon, recently began covering the sessions for Medicaid patients.

Who can doubt that such conversations are useful, helpful, humane, and more? But do we really need to pay doctors for them? And if so, how should such payments be structured?  The story goes on:

But the impact would depend on how much doctors were paid, the allowed frequency of conversations, whether psychologists or other nonphysicians could conduct them, and whether the conversations must be in person or could include phone calls with long-distance family members. Paying for only one session and completion of advance directives would have limited value, experts said.

“This notion that somehow a single conversation and the completion of a document is really an important intervention to the outcome of care is, I think, a legal illusion,” said Dr. Diane E. Meier, director of the Center to Advance Palliative Care. “It has to be a series of recurring conversations over years.”

Let's think this through. First, is such a payment--or set of payments--consistent with what many argue is the overall direction of health care payments, i.e., a capitated or global payment environment, or bundled payments for acute or long-term diseases?  By definition, no. Why are we thinking about adding a new fee-for-service billing code if the trend is away from that?

Second, is it all really necessary anyway?  I look at the experience of Gundersen-Lutheran Hospital in Wisconsin, which put in place a series of end-of-life discussion with their patients.  As I noted in this blog post over two years ago [emphasis added]:

Here’s the real lesson.  If we view things in this manner, any place in the world can do it.  It does not depend on new government policy.  It does not depend on a change in payment methodology.  It does not depend on accreditation rules and regulations.  The power to make these kind of change resides in the people who have been given the privilege and responsibility of running our health care institutions.

In short, the necessary condition for this kind of approach to be adopted is the support of executive and governance leaders.  That leadership often is based on a remarkably simple set of values, tied to a clear sense of institutional purpose.

As noted by Gundersen Lutheran CEO Jeff Thompson:

Why we pressed down this path has everything to do with the well-being of patients, families, and the health professionals who care for them. It is to preemptively answer the question, “What would your parent, your spouse, your loved one want in this situation?”  The purpose is to avoid anyone needing to say, “We wish we knew.”

As stated in the book, Having Your Own Say:

This breakthrough is not a new drug or test or treatment; it is a new way to organize our care of patients with advance illness so that they can live as well as possible for as long as possible in the way of their own choosing.  The “miracle” is that this new care depends more on human interaction and coordination than on technology and science.  The wonder is that it costs less to deliver but is actually better.


Bart Windrum said...

Paul I began believing years ago, and continue believing today, that the best thing medicine could do for the citizenry would be to make a formal statement regarding dying in the 21st century attesting to its complicated nature, and saying that the primary responsibility for peaceful dying is with individuals and families, who must each and all engage in a long-term educational projects. I won't blather about the details as I see them.

I have also long felt conflicted about medicine's self-apponted role regarding dying. It's admirable to try to take on and solve this problem for people. It's also arrogant, the logical outgrowth of a misplaced, ultimately paternal sense of ownership.

I can attest, after attending numerous EOL evening panel discussions at which community players (higher ed, hospice, etc) invite the interested public to hear medicine's best guidance, that I have come away every time with a deepening feeling of dismay at what I perceive as the overall shallowness, this due to ignoring the myriad aspects that require mastery by citizens in order to die in peace.

I am always glad to hear of useful initiatives within medicine to help resolve, if not solve, gnarly EOL issues that result in non-peaceful dying. I remain critical along the lines I've assessed medicine's guidance to assign/acquire advocates and bring one/them along when hospitalized. Medicine tells us to advocate, but now why (too scary) nor how (too complicated). This scenario extends to EOL guidance.

Barry Carol said...

We hear all the time about how time constrained primary care doctors are. They say they have to see many more patients these days and have less time to spend with each one. Reimbursement rates for evaluation and management codes are low while doing procedures are rewarded much more generously. At the same time, there is a lot of resistance to capitated and shared risk / shared savings contracts because hospitals and doctors are reluctant to take on financial risk.

There is also the issue of who has the responsibility to initiate a discussion about end of life care and how long should it take, on average, for a patient to make a determination about what care he or she wants and doesn’t want in an end of life situation? It can be a very difficult and uncomfortable discussion which many doctors are understandably reluctant to initiate especially if the patient is already close to the end of life.

My lawyer tells me that in NJ, hospitals will do pretty much whatever the family wants if the patient can’t speak for himself and has no prior documentation in the chart. The problem then is that there is often disagreement among family members. I would be interested in learning more about the protocol at Gundersen-Lutheran.

Serena Curler said...

From Facebook:

Thank you for sharing! I agree that these conversations are a new way to organize and deliver care and not a one time conversation. To me, this shows that the need is being recognized and I feel Palliative care teams can help lead others in the direction of having these conversations or being available on consult for the really challenging ones. Lastly, Palliative Care is being incorporated into resident programs. I don't think it needs to be a new charge. We bill for time and the revenue doesn't support the program enough but the cost savings does. Our cardiologists have recognized that in our readmit data.

Beverly Heywood Rogers said...

From Facebook:

The idea of paying for such conversations does more to point up the absurdity of our current reimbursement situation than any discussion of its own merits.

Anonymous said...

I dont know. If this is about primary care docs getting paid for more of what they do, I would support it. They get the shaft worse than any one and I've got a good one who deserves to get something good.

Barry Carol said...

As noted before, these discussions can be difficult and uncomfortable. One option for people who have given the subject some thought, with or without consultation with a doctor or palliative care specialist, is to write down your thoughts. My wife and I did exactly this and showed it to our lawyer. He said to just attach it to our broadly worded living will and that should be fine. We also sent a copy to our son and told him to put it with his other important papers. It can be updated, changed or withdrawn at any time.

While it is probably not possible to cover every conceivable contingency, some color on what care is wanted and not wanted in the event of advanced dementia, late stage cancer, severe congestive heart failure, ESRD, etc. can be very helpful in providing guidance to family members who may have to make EOL decisions on the patient’s behalf.

Bruce said...

It's not so clear that Medicare doesn't or can't pay for these conversations now. Medicare and other payers pay for most non procedural physician encounters as "evaluation & management" visits, represented by a series of codes for length of visit (e.g. 20, 35, 45 minute visits). Sessions that are primarily management discussions can be billed by time. It's management for the patient's disease - e.g. a code for breast cancer. You can't make informed treatment choices without an informed patient. A claim for a 45 minute management session for a cancer patient which was primarily discussion would usually process as any other office visit. To my knowledge no Medicare policy disallows informed management that revolves around late stage care. An end of life discussion for a well patient would be harder to code appropriately. This is, of course, a narrow comment on the issue; I recognize the author's and other commenters' depth of concern with the arbitrary and dysfunctional "payment system" but that is the only aspect I am addressing.

Anonymous said...

I work within a large health system in the mid-atlantic area. We are in a state of "money grabbing". Physicians are talking in terms of bundling and capitation but their behavior is greedy. The end of life conversation and planning issue received a lot of discussion over the past few months within our system. Repeatedly the prime topic of the discussions is reimbursement. The secondary topic is about what is right for the patient.

I am very disappointed that this will become another added cost to health care in this country.

Barbara Rose said...


I think you are missing an important point on this one. I am in the second year of a 3 year , locally funded intervention to improve advance care planning in the community (check out ConversationsOfa

I agree that advance care planning is part of good care planning but most physicians don’t do it-- neither PCP nor specialists.

Many cite time but its also fear of emotion.

Our project coaches physicians to have earlier ACP conversations, trains support staff using the Gundersen ‘Last Steps’ curriculum, improvements in Epic for better documentation and initiated a community engagement campaign.

I think that paying drs. (esp. primary care) for their time to initiate a specific ACP conversation, can help normalize the ACP process and bring attention to the importance of it.

Too many people suffer at the end of life (data supported) because ACP didn’t happen in families or the health care system.

nonlocal MD said...


"I think paying drs........for their time to initiate a specific ACP conversation, can help normalize the ACP process and bring attention to the importance of it."

In my interactions with physicians as a patient or family member recently, I have experienced some truly bizarre comments from them (the most recent: a doctor whom I have asked to call to update me on my mother's ER visit initiates the conversation with: "Thank you for speaking with me. I appreciate it." Huh????)
I get the definite feeling they are speaking from some script that tells them how to be nice or something. I fear that these ACP conversations, if isolated and reimbursed as a specific 'procedure', will fall into the same category - a rote script-driven recitation that the patient can easily see through and therefore not trust, after which all the proper boxes are checked and the reimbursement is awaited.
Is this what we want our medical care to look like? I reiterate, the reimbursement system is absurd and we need to recruit different types of people to be physicians, if they latch on to the reimbursement first as anon 8:04 indicates.