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David Fisher, MD, MPH: Reimbursing doctors for discussing goals of care with their patients- finally, a good health care reform idea!

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Wednesday, July 29, 2009

Reimbursing doctors for discussing goals of care with their patients- finally, a good health care reform idea!

Part of the proposed health care reform bill that I like is the idea to reimburse physicians for having an "advance care planning" discussion with their patients once every 5 years. This is something I do with my patients often, and I have wished many times that Medicare would recognize the value of this skill, and the time it takes to perform it, by offering specific reimbursement for the discussion. Unfortunately, some Republicans are saying that supporting a patient-physician conversation about goals of care and end-of-life options will "start us down a treacherous path toward government-encouraged euthanasia". I disagree.

Section 1233 of HR 3200, the proposed health care bill, is titled "Advance Care Planning Consultation". It allows a physician to be reimbursed for leading his or her patient in a discussion about the patient's wishes in certain medical situations. I find these discussions to be very helpful for patients and doctors. Patients have the chance to think through different scenarios and ask questions about what to expect. They also have the opportunity to put these wishes in writing, and to select a surrogate decision maker for a situation in which they are unable to express their own wishes. Doctors can gain insight into their patient's preferences so that, when they become ill, the doctor knows better how to care for them. Family members are often involved in these discussions, and the process helps prepare the entire family for unexpected events so they don't have to panic in a crisis. These discussions often occur around the time of a new diagnosis, a serious change in condition, or a change in living situation such as a move to a nursing home.

The bill does not mandate these discussions, as some commentators and even congressmen have suggested. It simply rewards clinicians for taking time to assist their patients with advance care planning, if they chose to do so. The bill also does not mandate the specifics of the conversation. It mentions many of the standard treatments that are discussed in an advance care planning session, such as intravenous antibiotics, artificial feeding and hydration, and hospitalization. The bill does not mandate what is said or decided about these issues; it simply allows that they can be part of a conversation that would qualify as advance care planning.

My only concern about a bill like this is that it recommends: "An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title". I am a staunch supporter of palliative care and hospice, when appropriate, but in states where physician-assisted suicide (PAS) is legal, the phrase "continuum" could be used to mandate that physicians offer this option to their patient in any advance care planning discussion. However, the bill states that this discussion can include such an explanation, not must, so the bill as it is currently written would not mandate offering PAS even where it is legal.

Though I have many problems with HR 3200, and I hope it does not pass in its current form, I am encouraged that reformers are recognizing the value of advance care planning, and that they are considering reimbursing physicians for taking time to providing this valuable service to their patients.


Dr Bob said...

Thank you for this thoughtful discussion. AAHPM and NHPCO have also put out statements basically saying the same thing. I very much appreciate your mention of the dangers relative to PAS/euthanasia. My fears are that these misconstructions of what good advance care planning are will detract from the true issues surrounding palliative and hospice care. Clearly, these are highly valuable discussions, and there is no current reimbursement mechanism for them. We need to move beyond the idea that our work is "the visit", and learn (and pay for) the idea that our work is THE CARE.

hospiceLCSW said...

As a medical social worker I have discussions with my patients everyday that I consider paramont to informed consent. If a physician agrees to care for a patient then isn't it understood that part of that care involves going over options, what if's. If I have heart disease, if I'm over age 50, if I have a asthma for that matter...I expect my physician to say..."In order for me to do my best in providing medical care for you, it is important that i understand what your preferences are regarding your care...Right now you are realitivley healthy but i plan on taking care of you for a long time...i'd like you to take some time to think about what kinds of treatments or interventions you would want if at some point in the future you develop a life threatening illness that i can not cure. Make no mistake i will be as aggressive with treatment for as long as you want me to but i do want you to think about if there would ever be a time or a scenerio when you'd want me to stop treating you aggressively." Having had hundreds of these conversations with patients over the last 10 years I know how lenghty they can become...but isn't this type of conversation the backbone of what a physician-patient relationship is? I am not opposed to physicians getting paid to have this conversation...i just think it is sad to think that a physician would have this conversation if she/he could get paid for it but wouldn't if they couldn't get reimbursed. My theory is that if a physician is not having this conversation with their patient already then attaching money to it will not motivate phyisicans to have these conversations. How about passing a piece of legislation which mandates it. How about offering a class in medical school on communicating bad news, or how to have end-of-life conversations with your patients. ~Audrey

thedoglady said...

My mother died 10 months ago of cancer at the age of 72. I'm 50 and want to know what papers my husband and I should have to make sure if one of us in incapable of making decisions, the other can show the doctors exactly what to do. Living Will, DNR, medical power of attorney? Things are so complicated for patients these days. Can you advise?

risaden said...

Your post is featured in this month's palliative care Grand Rounds!

David Fisher, MD, MPH said...

Thanks for the comments everyone. To answer thedoglady's question, I have a post about the Power of Attorney for Health Care, what I believe is the most useful and important advance care planning document.