Proponents of better care at the end of life cheered when The Center for Medicare/Medicaid Services recently announced that after almost six years of debate, Medicare will start paying doctors to have end-of-life-care discussions with their patients. Advance-care planning is a discussion of a person’s goals, values, beliefs and fears about what medical decisions might be made for them in the future, and includes an Advance Health Care Directive, a legal document that specifies what actions should be taken should they no longer be able to make decisions about their care.
This is a good first step. Studies have shown that advance-care planning not only improves the quality of care for the person in question, but has lasting positive impact on the entire family. Moreover, it is considered a key step in reducing the costs associated with non-beneficial medical interventions in advanced illness.
But the proposed level of reimbursement for this complex process is not sufficient to encourage physicians to carry this out properly, nor does it address the perverse incentives of physicians and hospitals to “do more” even when it is clear that further interventions will not result in extending life with an acceptable quality of life. Additionally, until our society becomes more informed about medical decisions that are often required near the end of life, patients and their families may not be able to ensure that their wishes are honored by the medical system even if the proper documents are in place.
Many assume that the biggest obstacle to advance-care planning has been the specter of “death panels,” as Sarah Palin called it in 2009. But the real obstacle may be financial.
Someone is benefitting from all this end-of-life care, and it’s probably not patients. For example, recent studies have shown that limiting the amount of aggressive care in the setting of an advanced illness may actually prolong life. The real beneficiaries of “do all” medical care are hospitals and doctors. Although no physician feels he or she is providing care near the end of life for monetary gain, consider evidence that health care spending in the last weeks of life is linked to how physician and hospitals are compensated for that care.
Medicare now proposes to pay only $86 to physicians for the first 30 minutes of advance-care planning consultation and $75 for a follow-up consultation. In my experience doing advance-care planning with families in San Francisco, these conversations took several hours to complete. The first conversation, which includes a lot of education about life-prolonging medical interventions and a discussion of the person’s goals and wishes would take at least an hour and a half. In our practice, we followed up with another hour-and-a-half meeting with the whole family present to explain the decisions and answer questions. I cannot see how a physician could do this in less time, unless their patient had already given these issues considerable thought.
By comparison, consider that a physician makes about $400 on average to perform a colonoscopy, which takes much less time. A colonoscopy takes skill and practice to do well, but so do advance-care planning discussions. This is especially true when the person creating the plan has a significant illness. Despite this, very few doctors are trained to do this well. If we are going to pay doctors to talk to their patients about end of life, we must implement training for having difficult conversations into our medical training curricula, both in medical school and post-graduate training programs.
A study in 2013 showed that almost half of those over 65 required someone to make a medical decision for them within 48 hours of admission to the hospital. This person is most often a family member.There are already more than 13 million such hospitalizations every year, and in the coming years there will be many more.
We must educate families about the types of decisions many people have to make on behalf of someone else in a critical situation, such as whether to place their loved one on a breathing machine or to have CPR in the event of cardiac arrest. Most people understand how to pick a credit card or bank loan, but few people know how to ask the right questions about end-of-life care, especially in light of their own preferences. Increasing our nation’s medical literacy is an absolute imperative.
The new policy to reimburse physicians for advance-care planning has important symbolic implications for the practice of medicine. But without training physicians to do this hard work, paying them appropriately, aligning other payment incentives, and orienting the public to these difficult decisions, we are not going to see a change in end-of-life experience or cost in the U.S. anytime soon.