Planning for care at the end of a patient’s life is an uncomfortable yet necessary conversation. Without it, a doctor won’t know if the person wants to be resuscitated, placed in hospice or subjected to advanced treatments to prolong his or her life. It can also avoid costly treatments and family fights that, in hindsight, were unnecessary.
Yet, even with physicians now being compensated for having these discussions with their aging patients, only a small portion of Medicare beneficiaries are receiving the counseling. According to Kaiser Health News, in 2016, the first year the government allowed health care providers to bill for advanced planning talks, close to 575,000 Medicare beneficiaries engaged with their doctor on the topic. That accounts for a little more than 1 percent of the 56 million Medicare beneficiaries in the U.S. What’s more, nearly 23,000 doctors billed the government for these conversations amounting to $93 million.
At first blush, an adoption rate of around 1 percent seems very low, but experts say the number should start to increase in the months ahead. “There are a lot of barriers,” says Donald Taylor, a professor in the Sanford School of Public Policy at Duke University in Durham, North Carolina. “If you look at the data it has shown increases that you might expect, but it’s still relatively low.”
Before 2016, if doctors wanted to have discussions with their patients about end-of-life care, they would have to carve out time on their own dime. Oncologists, heart doctors and other specialists have always included advanced care planning discussions with their patients if treatments fail, but overworked family physicians and general practitioners simply didn’t have the time to have these conversations in a meaningful manner.
Medicare Compensates Doctors for Advanced Planning Talks
Recognizing these planning conversations weren’t happening frequently enough, leading in some cases to costly medical treatments that weren’t wanted, the federal government added compensation for advanced planning conversations into its fee schedule on Jan. 1, 2016. The thinking is that if doctors are compensated for these conversations more of them will happen. “Sometimes having these hard conversations are time-consuming and doctors wouldn’t get paid extra,” says Judi Lund Person, vice president of regulatory and compliance for the National Hospice and Palliative Care Organization, a trade association in Alexandria, Virginia. “Having the [insurance billing] code and having payments encourages physicians and other practitioners to spend the time necessary for these conversations.”
While the talks aren’t legally binding, having several conversations with patients can go a long way in making sure their wishes are carried out and family members aren’t left bickering about what mom and dad may or may not have wanted. It also empowers the patient, ensuring his or her wishes are met. These discussions typically focus on whether a patient wants to be resuscitated, whether or not he or she wants to go into hospice, what treatments doctors should subject them to and what they should ignore. The number of end-of-life planning talks is expected to see an uptick in coming years, with many experts pointing to 2016 results as an encouraging starting point. After all, it represents more than 500,000 people who didn’t have these conversations in a substantive way before, which Lund Person says is an “impressive” feat. It’s also higher than the 300,000 the American Medical Association had predicted would use this service in the first year.
Roadblocks Prevent a Bigger Adoption Rate
There have also been several barriers erected that have prevented doctors from offering such discussions. Take the billing systems for starters. According to Taylor, it took Duke University five to six months to have the ability for its providers to bill for the service, and it is a health system with the manpower and financial wherewithal to implement the new code. What’s more, the compensation for it is relatively small, $86 for the first 30-minute visit and $75 for each follow-up conversation – playing a role in the low adoption rate among some physicians, Taylor says. He points to a Duke Survey that showed some doctors didn’t think the extra pay was worth it, while others signaled they would begin offering it now that they will get compensation for their time. Then there’s the communication barrier on the part of the federal government that is preventing more advanced planning talks from happening. According to Taylor, Medicare didn’t issue a national coverage determination for the new compensation, which provides details on how and what can be billed. Without it, providers are taking more time to get up and running, he says. Not to mention many don’t even know they will get compensated for end-of-life care planning conversations.
More Doctors Expected to Provide These Talks
Despite the seemingly sluggish adoption of advanced care planning, everyone agrees the rate will increase as doctors get more comfortable with these type of discussions and their billing systems are able to handle the update. It’s also expected to increase as more patients take control of their care in this era of self-directed health care. There are already signs emerging. Dr. Michael Munger, a family physician in Overland Park, Kansas, and president of the American Academy of Family Physicians, says he polled the 100 primary care physicians in his health care system and found over the past several months more patients are receiving the service. “More doctors will start doing this, even myself, now that it is structured,” Munger says. “Doctors are recognizing this doesn’t have to be an afterthought. They can now set aside time to have this important discussion.”