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End-of-life care comes to the forefront


Even if Medicare doesn't reimburse physicians for consultations, patients still want to talk about their care preferences

As we witness the aging of America, end-of-life issues will become ever more political, economic and emotional, but those perspectives cannot each be presented singly if we hope to improve on the actual “care”-in every sense of the word-delivered to individual people in the last few months of life. Often, the emotional component is trump.

But that shouldn’t stop economists and politicians from examining possible solutions for optimizing care without driving up costs unnecessarily. The Affordable Care Act (ACA) provides for Medicare physician payment for annual wellness visits, and end-of-life consultations can be part of those visits. However, Healthcare Common Procedural Coding System (HCPCS) code S0257, which documents “counseling and discussion regarding advance directives or end of life care planning and decisions,” itself is not reimbursable as a Medicare service.

ACA was supposed to have such a provision for reimbursement, but it was revised in response to the “death panel” flak introduced by vice presidential candidate Sarah Palin in 2009.

“Providers can offer advance care planning through the ‘Welcome to Medicare’ visit, but it is not reimbursed specifically, and to my knowledge, it is not a required component of the visit in order to be paid,” Tom Valdivia, MD, MS, co-founder and CEO of Luminat, told me. His company provides a platform for practical management of advance-directive processes. 

Even though advance care planning is purely voluntary between patients and their physicians, both parties have historically been squeamish about beginning the conversation. It doesn’t have to be that way.

Courage to speak

While many are concerned, few are courageous enough to talk about dying. And that’s something the grassroots campaign, the Conversation Project, aims to change.

The advocacy group began in 2010 to transform the culture of end-of-life situations from grief, guilt and uncertainty to engagement, respect and communication for patients and their loved ones. It now has the collaborative backing of several organizations, including the Institute for Healthcare Improvement and teams of health experts in clinical and non-clinical disciplines.

Too often, a patient’s preferences for end-of-life care are unknown to the family. In fact, 90% of consumers agree that making their wishes known is important, yet only about 30% have expressed them, according to the Conversation Project’s research.

The organization’s online tools center around ways to discuss care preferences, helping patients get their thoughts together rather than providing legal forms or written directives. Additional guides detail how patients can voluntarily start those conversations with physicians on end-of-life priorities.

Traditionally, hospice providers have had the lead role in engaging patients and families, but the process must begin much sooner, when there are fewer dire circumstances. Health plans are beginning to embrace non-directive care support tools for their populations, generally through third parties, and are referring more members to hospice earlier.

The next decade presents an opportunity to advocate for your members in the most sensitive way possible with tools meant to prompt the dialog with providers-most likely during the Medicare annual wellness visit. When members are able to express their wishes proactively and in a thoughtful way, they’ll have some peace of mind and so will their families. 



What the Conversation Project can do to change the culture:





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