Medicare said Friday it will pay doctors to help patients plan what kind of care they want at the end of life, an idea more broadly accepted than six years ago when it touched off a political uproar about “death panels.” The policy change was urged by numerous physician and health groups. Some doctors provide this “advance care planning” to their patients without getting paid for the counseling time, and some private insurers already reimburse for it.
But the Obama administration’s policy change could make the talks more common among about 55 million Medicare beneficiaries. The rule, proposed last summer and finalized Friday as part of broader doctor-payment regulations, takes effect Jan. 1. The counseling is entirely voluntary, and could take place during seniors’ annual wellness visit or during regular office visits.
“As a physician and a son, I personally know how important these discussions are for patients and families,” Dr. Patrick Conway, Medicare’s chief medical officer, said in an interview. “We believe patients and families deserve the opportunity to discuss these issues with their physician and care team.”
Most Americans say they’d prefer to die at home, with treatment to free them from pain. But the landmark “Dying in America” report from the prestigious Institute of Medicine found the reality too often is unwanted invasive care and not enough comfort, in part because too few people make their wishes known to their doctors and loved ones.
The movement toward what’s called advance care planning also reflects that this isn’t just an issue for people who already are seriously ill, but a process that may prompt different decisions at different stages of life. Involving a doctor in those decisions can help people fully understand their options. A relatively healthy person might want all-out efforts to resuscitate them after an accident, for example, but if diagnosed with advanced cancer, might make different decisions as their health gradually worsened.
Medicare decided not to limit how often such counseling could take place, Conway said, in part because of feedback from doctors and the public that people may need repeat counseling as their health needs change. “If you made a choice and you become more ill, you might want to have the discussion again,” Conway explained. “For some patients, it may need to occur multiple times in a year if they’re quite ill and their circumstances may change. For other patients, they may not need this service at all in a year.”
Medicare’s new policy “is a turning point in end-of-life care,” said Oregon Democratic Rep. Earl Blumenauer, a longtime congressional proponent of coverage for such counseling. He said next steps include helping ensure that advance directives for all patients are easily accessible and updated frequently, and that doctors are trained to have these difficult conversations.
“Ultimately, the care provided must align with the patient’s stated goals values, and informed preferences,” Blumenauer said. About three-quarters of the people who die each year in the U.S. are 65 and older, making Medicare the largest insurer at the end of life, according to the Kaiser Family Foundation.
For years there had been bipartisan consensus about helping people to better understand their end-of-life choices. A 1992 law passed under Republican President George H.W. Bush requires hospitals and nursing homes to help patients who want to prepare living wills and advance directives. Momentum stalled with political outcry over including end-of-life conversations in President Barack Obama’s health care law, which some opponents termed “death panels.”
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