Medicare and End of Life Planning

GOVERNMENT

Medicare about-face on end-of-life planning pay

Medicare started covering voluntary advance-care counseling during annual physicals, but it rescinded the policy after only five days when the issue again proved toxic.

By David Glendinning and Chris Silva, amednews staff. Posted Jan. 10, 2011.

Washington -- In a surprise turnaround, the White House announced Jan. 5 that it was undoing a 2011 Medicare policy that would have paid physicians to advise patients about end-of-life care and other advance-care planning during annual wellness visits.

The new Medicare payment policy had gone into effect on Jan. 1. It was unveiled on Nov. 29, 2010, in a Centers for Medicare & Medicaid Services final rule that outlined doctors' 2011 pay rates. It stated that the program would cover voluntary advance-care planning consultations, including discussion about setting up an advance directive that would guide physician care if a patient became too ill to make medical decisions.

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A CMS official explained Jan. 5 that the language was being removed because it had not been included properly in a proposed version of the rule released earlier in 2010. But the reversal, confirmed shortly before this article's deadline, appeared likely to prompt speculation that it was an attempt by the White House to avoid a political battle with House Republicans, who officially took control of that chamber the same day the policy was revised. The CMS official asked not to be named because the change had not been announced formally.
When it was raised during the health system reform debate, advance-care counseling prompted a furious backlash from reform critics, who said the effort was one of several that would lead to government-sanctioned euthanasia. It was one of the primary elements feeding warnings about federal "death panels."
Under that proposal, doctors would have been able to bill Medicare separately for advance-care planning consultations once every five years, or when a patient's health changed dramatically. The plan also suggested that physician performance could be measured in part by whether patients had advance directives or living wills. Under heavy fire, its authors stripped the provision out of the reform bill.
The latest Medicare policy was significantly pared down. Had it stayed in effect, physicians would not have been paid a separate rate for the service. It would have been included as part of the fee for the wellness visits that Medicare already covers.
But despite noting that such a benefit already exists for incoming seniors under the "Welcome to Medicare" physical, a policy put in place by the George W. Bush administration, the White House was unable to avoid controversy again. Reform law critics suggested that the Obama administration was attempting a regulatory end-run around a Congress that had already rejected the concept.
"Seniors rightly fear there is a potential conflict of interest if the government is paying for end-of-life counseling and also for our end-of-life health care," said Grace-Marie Turner, president of the Galen Institute, a Washington, D.C.-based research group dedicated to free-market health policy ideas.

Recognition deferred

The policy reversal meant many physicians who have called for Medicare to recognize the value of advance-care planning will need to wait longer to achieve that goal.
The CMS official said nothing about the change would prevent beneficiaries from having end-of-life care discussions with doctors. But the talks would not be covered officially.
Physicians said paying for end-of-life care consults during physicals would recognize the work doctors have done for years and help promote the need for the discussions to a wider audience. They said research shows having such talks increases the quality of life for seniors and their caregivers and helps sort out options before a medical crisis occurs.
"The AMA supports Medicare reimbursement for physician advance-care planning consultations with a patient," American Medical Association President Cecil B. Wilson, MD, said before the new pay policy was reversed.
"We encourage physicians to have these discussions with their patients before a serious illness strikes to ensure patients have the information they need, sufficient time to carefully consider their options, and the opportunity to make their care preferences known if they choose to do so."
At least one physician organization suggested, before the reversal, that the Medicare benefit should be even more robust.
"ACP supports greater recognition and adequate Medicare reimbursement for extended and complex counseling required for physicians to develop end-of-life care plans for their patients," said J. Fred Ralston, MD, president of the American College of Physicians.
Jon Radulovic, a spokesman for the National Hospice and Palliative Care Organization, said acknowledging the need for end-of-life care counseling through Medicare was the smart thing to do.
"If someone met with a financial planner, they would be told about a number of tools that could fit their needs, and the planner would be compensated for their time," Radulovic said.
"Why wouldn't you want to give the same attention to your medical health as your financial health?"
David Casarett, MD, a palliative care physician and associate professor of medicine at the University of Pennsylvania, said the policy reversal was the wrong decision.
"This is a substantial setback for patient choice and autonomy, a sad disappointment," Dr. Casarett said.
The print version of this content appeared in the Jan. 17 issue of American Medical News