The Move Could Help Reduce Unwanted Care and Promote Statewide Initiatives to Educate Patients and Physicians on Palliative Care
Economics Feature — June 2016
Tex Med. 2016;112(6):31-36.
By Amy Lynn Sorrel
Houston geriatrician Hattie Henderson, MD, sees new patients every day in nursing homes, most of them older with debilitating illnesses from which they are unlikely to recover. That's when the hard conversation starts.
"I'm the bad-news doctor they're seeing in a strange new place because they've never had a discussion with their [regular] physician about the kind of care they would want at the end of life. I don't know their wishes," she said.
Advance care planning is not a quick conversation. For years, Medicare did not adequately pay physicians for the significant time they must invest to discuss emotional topics like patients' disease process when faced with a life-threatening illness; treatment preferences, whether palliative options that alleviate symptoms or more extreme life-sustaining measures like resuscitation or intubation; and who will carry out their wishes when they can't speak for themselves.
"These are very difficult decisions for families and doctors when things happen acutely and you don't know what patients want," said Dr. Henderson, a member of the Texas Medical Association Council on Health Service Organizations and a statewide advisory committee on palliative care.
She's hopeful Medicare's recent reversal will make those conversations a routine part of care. As of January, Medicare pays physicians for advance care planning as a separate service, a long-sought victory that promotes medicine's goals for educating patients and physicians on the issue.
TMA and the American Medical Association advocated for and cheered the change, which Dr. Henderson describes as "a long time coming." In fact, a 2015 Kaiser Family Foundation poll found patients expect Medicare to cover these conversations with their physicians, but few are having them. (See "Time to Talk.")
Medicare previously covered advance care planning as part of the initial "Welcome to Medicare" visit for newly enrolled patients. Recognizing patients may not need the services right away, the Centers for Medicare & Medicaid Services (CMS) created two new payment codes that cover it as a separate service in physician practices and facilities, including hospitals.
"Additional practitioner time to conduct these conversations provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families," states the final rule, which largely followed AMA recommendations. It goes on to say the change "will better enable seniors and other Medicare beneficiaries to make important decisions that give them control over the type of care they receive and when they receive it."
The two new codes, 99497 and 99498, cover voluntary, early conversations about end-of-life care options, both before an illness progresses and during the course of treatment. The first code covers the first 30 minutes of face-to-face time with a physician or qualified health professional trained to discuss and document the conversation, including completing forms like advance directives. The second code covers additional 30-minute blocks of time. In Texas, Medicare pays around $83 and $75, respectively.
For now, TMA officials say CMS has not put a frequency limit on the codes, so physicians can provide and bill for the service as patients' needs might change, although Medicare will monitor the codes' use. For more billing details, read this Jan. 13 TMA Practice E-Tip.
Early drafts of the Affordable Care Act contemplated payment for end-of-life planning, but the policy got mired in controversial mischaracterizations of so-called "death panels."
"That's never what it was about. What it's about is taking the time that you need to talk with patients in order to find out what they really want and what are their goals and values for care. You can't do that in a 30-second interview at an exam table. It does take time, and that time needs to be reimbursed, and historically, payers have not paid doctors for their time," said Stuart C. Pickell, MD, a Fort Worth internist and pediatrician and member of TMA's Council on Health Service Organizations. "There has been a lot of unwanted care that ends up getting delivered to patients who, if they had the option to think through it ahead of time, probably would have opted out of the care they ended up getting."
Roughly one-quarter of traditional Medicare spending is for care provided to patients in their last year of life, according to Kaiser Family Foundation research. And while most adults say they would prefer to receive end-of-life care at home, data show that only one-third of Medicare patients actually die there.
Delegates at the 2015 AMA Annual Meeting last June passed policy urging insurers to pay for the counseling. Speaking of CMS' initial proposal at the time, AMA President-Elect Andrew W. Gurman, MD, said the draft rule "affirms the need to support conversations between patients and physicians to establish and communicate the patient's wishes in responding to various medical situations. The AMA has long supported coverage of advance care planning and provided recommendations and input to help Medicare create a payment policy based on a full understanding of this medical service."
A Sept. 1, 2015, TMA comment letter also praised CMS for supporting physicians' and patients' mutual goals of honoring patients' end-of-life care choices. "Physicians need information about patient preferences, and patients need explanations about treatment options in order to make informed decisions," TMA officials wrote. And because patient preferences can change over time, compensating physicians for the service allows physicians to revisit and document those decisions on a regular basis.
A Difficult Conversation
Poor payment mechanisms were just one of several barriers to bettering end-of-life care that the Institute of Medicine (IOM) identified in its seminal 2014 report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.
Also among the IOM's top recommendations were improving physician training and increasing public education on the subject.
To help overcome those hurdles — as well as avoid the drawn-out legislative battles over end-of-life issues that have characterized past sessions — the 2015 Texas Legislature established a Palliative Care Interdisciplinary Advisory Council. Spearheaded by Rep. John Zerwas, MD (R-Richmond), TMA-supported House Bill 1874 charges the council with setting up a statewide patient and physician education program at the Health and Human Services Commission (HHSC), as well as evaluating availability, barriers, and practices regarding patients' rights related to palliative care. The advisory council, which includes representatives from physician, nurse, social worker, religious, and patient advocacy groups, expects to publish its first report to the legislature by Oct. 1.
"This will be great for patients and physicians to give them a level of confidence when they have these discussions and to really learn what palliative care means," said Dr. Henderson, who serves on the advisory council. "Some doctors feel guilty discussing these things with patients, as if they are telling patients not to have hope, but that's not true. My hope is always that they are able to get better and go home. But if that's not the case, I want to be able to respect their wishes. And that could mean patients want every measure available, but someone needs to discuss that with them."
Although the Medicare payments are directed at older patients, Dr. Pickell adds end-of-life care is a conversation physicians should have with all of their adult patients, to varying degrees. "If you're 25 and healthy, maybe your advance care planning is designating your parents or someone else to make decisions for you if you can't."
The independent practice association Dr. Pickell belongs to leads an initiative to encourage physicians to discuss patients' future care preferences through conversations with their families and caregivers. The North Texas Respecting Choices program trains doctors and other health care professionals and facilitators to start those talks and record them in patients' medical records. The project is modeled after La Crosse, Wisc.-based Gundersen Health System's comprehensive advance care planning program by the same name developed more than 20 years ago.
Kaiser research shows that about one-quarter of Americans aged 65 and older do not have advance directives or have not written down their end-of-life care wishes. Data from Gundersen's Respecting Choices program, on the other hand, show that in 2010, among those adults who died in any setting of care in La Crosse County over a seven-month period, 96 percent had some type of advance care plan, 99 percent of those plans were available in the patients' medical records, and treatments were consistent with instructions 99 percent of the time. The program also shows reduced hospitalizations and associated costs and increased patient satisfaction.
TMA is investigating a statewide Texas pilot after medical societies in Minnesota, South Carolina, Washington, and Wisconsin collaborated on similar models.
The North Texas Respecting Choices program, for example, offers an eight-hour training course for health professionals who might facilitate end-of-life conversations with their patients.
The program also created an abbreviated course for physicians who don't have the time for extensive training. After introducing an end-of-life care discussion, for instance, physicians can refer patients to Respecting Choices-trained facilitators for more in-depth talks and conclude the visit by certifying the decisions made were in line with the patients' desires.
Dr. Pickell notes Medicare payment rules allow for physician-supervised health professionals to facilitate the discussions, and physicians can still bill for it. For the most part, nurses and social workers in his practice handle the conversations, "and if they can't answer specific questions, the patient is referred back to me."
His practice uses educational videos to help patients understand some of the more complex aspects and options associated with advance care planning, such as artificial nutrition and hydration, intubation, out-of-hospital cardiopulmonary resuscitation, and do-not-resuscitate orders. To help identify those patients who might benefit from such counseling, the practice also asks its doctors whether they would be surprised if any of their patients were to die in the next year.
"These patients usually are not sick enough for hospice, but they are sick enough that their care team needs to know their treatment goals," Dr. Pickell said. "There is a lot of money wasted delivering care patients don't want because we never gave them the opportunity to opt out. We need to invest that money on the front end in the form of meaningful conversations so that patients get the care they want and not the care they don't."
But conversations around patient preferences mean little unless physicians document them, whether by helping patients complete a living will, advance directive, or other records.
At press time, TMA's Board of Trustees was considering recommendations by the Council on Health Service Organizations to support and educate doctors on a tool that could help standardize documentation of advance care planning statewide, known as Medical Orders for Scope of Treatment, or MOST, forms. The papers are Texas' version of the national Physician Orders for Life-Sustaining Treatment Paradigm, which translates patients' end-of-life preferences into physician orders.
Some Texas hospitals use a MOST form in palliative care or skilled nursing departments, for example. The North Texas Respecting Choices program adopted the model as a complement to other advance care planning documents, such as advance directives or medical powers of attorney.
Dr. Pickell introduces the MOST process after discussing patients' future care options. The document becomes part of the patient's electronic medical record so it can be updated if conditions change, and hospitals and emergency personnel can access it easily. Patients keep the original form, which travels with them to different care settings, whether a hospital or long-term care facility, for instance.
The four-part MOST document specifically delineates:
- Whether patients want resuscitation if found at home or out of a hospital without a pulse;
- If patients are not in cardiopulmonary arrest, what level of medical interventions they want, ranging from a hospital transfer, to comfort, or palliative, care;
- If patients do choose the full range of measures, whether they want to receive medically assisted nutrition or hydration and for how long, or if they want their physician to weigh in on whether such measures would enhance their care; and
- Whether the patient has completed a separate living will, medical power of attorney, or state-mandated out-of-hospital do-not-resuscitate order if they've chosen to forego such measures.
Once completed, physicians, patients, and their caregivers sign off in what Dr. Pickell describes as a collaborative process.
Dr. Henderson agrees a standardized MOST form could go a long way toward encouraging end-of-life discussions outside of crisis situations.
Even though the nursing and hospice settings she visits each use their own facility-specific palliative care forms, "the most important thing is it's written down," she said. "If everyone knows ahead of time what the patient's wishes are, the patient feels better. Their pain starts to decrease because they're not worried about what's going to happen next. The family is less stressed, and I can do my job" to ensure those wishes are respected in the patient's final days.
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Time to Talk*
Do you think doctors should discuss end-of-life care issues with their patients?
Have you had such a discussion with your doctor or health care provider?
Yes: 27% (aged 65 and older)
Do you think Medicare should cover these discussions between doctors and patients?
*Adults aged 18 and older unless otherwise stated
Source: Kaiser Family Foundation Health Tracking Poll, September 2015
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