Back from the dead: insuring end-of-life discussions

By Pam Bellcuk / New York Times News Service

DUNDEE, New York — Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans. People are living longer with illnesses, and many want more input into how they will spend their final days, including whether they want to die at home or in the hospital, and whether they want full-fledged life-sustaining treatment, just pain relief or something in between. Some states, including Oregon and Colorado, recently began covering the sessions for Medicaid patients.

But far more significant, Medicare may begin covering end-of-life discussions next year if it approves a recent request from the American Medical Association, the country’s largest association of physicians and medical students. One of the AMA’s roles is to create billing codes for medical services, codes used by doctors, hospitals and insurers. It recently created codes for end-of-life conversations and submitted them to Medicare.

Growing support

The Centers for Medicare and Medicaid Services, which runs Medicare, would not discuss whether it will agree to cover end-of-life discussions; its decision is expected this fall. But the agency often adopts AMA recommendations, which are developed in meetings attended by its representatives. And the political environment is less toxic than it was when the “death panel” label was coined; although there are still opponents, there are more proponents, including Republican politicians.

If Medicare adopts the change, its decision would also set the standard for private insurers, encouraging many more doctors to engage in these conversations.

“We think it’s really important to incentivize this kind of care,” said Dr. Barbara Levy, chairwoman of the AMA committee that submits reimbursement recommendations to Medicare. “The idea is to make sure patients and their families understand the consequences, the pros and cons and options so they can make the best decision for them.”

Now, some doctors conduct such conversations for free or shoehorn them into other medical visits. Dr. Joseph Hinterberger, a family physician in Dundee, New York, wants to avoid situations in which he has had to decide for incapacitated patients who had no family or stated preferences.

Recently, he spent an unreimbursed hour with Mary Pat Pennell, a retired community college dean, walking through advance directive forms. Pennell, 80, who sold her blueberry farm and lives with a roommate and four cats, quickly said she would not want to be resuscitated if her heart or lungs stopped. But she took longer to weigh options if she was breathing but otherwise unresponsive.

“I’d like to be as comfortable as I can possibly be,” she said at first. “I don’t want to choke, and I don’t want to throw up.”

With reimbursement, “I’d do one of these a day,” said Hinterberger, whose 3,000 patients in the Finger Lakes region range from college professors to Mennonite farmers who tie horse-and-buggies to his parking lot’s hitching post.

If Medicare covers end-of-life counseling, that could profoundly affect the American way of dying, experts said. But the impact would depend on how much doctors are paid, the allowed frequency of conversations, whether psychologists or other nonphysicians could conduct them and whether the conversations must be in person or could include phone calls with long-distance family members. Paying for only one session and completion of advance directives would have limited value, experts said.

“This notion that somehow a single conversation and the completion of a document is really an important intervention to the outcome of care is, I think, a legal illusion,” said Dr. Diane Meier, director of the Center to Advance Palliative Care. “It has to be a series of recurring conversations over years.”

Conflicting viewpoints

End-of-life planning remains controversial. After Sarah Palin’s “death panel” label killed efforts to include it in the Affordable Care Act in 2009, Medicare added it to a 2010 regulation, allowing the federal program to cover “voluntary advance care planning” in annual wellness visits. But bowing to political pressure, the Obama administration had Medicare rescind that portion of the regulation. In doing so, Medicare wrote that it had not considered the viewpoints of congressmen and others who opposed it.

Politically, the issue was dead. But private insurers, often encouraged by doctors, began taking steps.

“We are seeing more insurers who are reimbursing for these important conversations,” said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade association. The industry, which usually uses Medicare billing codes, had created its own code under a system that allows that if Medicare does not have one, and more insurance companies are using it or covering the discussions in other ways.

This year, for example, Blue Cross Blue Shield of Michigan began paying an average of $35 per conversation, face-to-face or by phone, conducted by doctors, nurses, social workers and others.

And Cambia Health Solutions, which covers 2.2 million patients in Oregon, Washington, Idaho and Utah, started a program including end-of-life conversations and training in conducting them.

Excellus Blue Cross Blue Shield of New York does something similar, and its medical director, Dr. Patricia Bomba, has spearheaded the development of New York’s advance directive system. Doctors can be reimbursed $150 for an hourlong conversation to complete the form, and $350 for two hours.

Hinterberger learned of Excellus’ coverage when he called recently to ask about end-of-life discussions, but even if he undergoes Excellus’ training to qualify for reimbursement, most of his older patients only have Medicare.

End-of-life planning has also resurfaced in Congress. Two recent bipartisan bills would have Medicare cover such conversations, and a third, introduced by Sen. Tom Coburn, R-Okla., would pay Medicare patients for completing advance directives.

But few people think the bills can pass.

Roadblocks

“The politics are tough,” said Dr. Phillip Rodgers, co-chairman of public policy for the American Academy of Hospice and Palliative Medicine. “People are so careful about getting anywhere close to the idea that somebody might be denying lifesaving care.”

Burke Balch, director of the Powell Center for Medical Ethics at the National Right to Life Committee, said in a statement that many doctors believed in “hastening death for those deemed to have a ‘poor quality of life.’” If Medicare covers advance care planning, he said, that plus cost-saving motivations would pressure patients “to reject life-preserving treatment.”

Doctors deny that.

“Honestly, sometimes I’m making an argument that treatment is not as bad as you think because of our ability to mitigate side effects,” said Dr. Thomas Gribbin, a Grand Rapids, Michigan, oncologist who recently persuaded two Michigan insurers to cover end-of-life conversations.

It is unclear if advance care planning saves money. But some studies suggest that it reduces hospitalizations because many people prefer to die at home or in hospices, so cost-saving can be an inadvertent result, said Dr. William McDade, president of the Illinois State Medical Society, which asked the AMA to create codes for the discussions.

The conversations do not lock people into decisions, and studies show that some change their minds in a crisis.

But evidence suggests that discussions can make a difference. One study found that cancer patients who previously discussed end-of-life preferences with doctors more often received care matching those wishes. Other studies suggest planning lowers stress in patients and families.

Reimbursement rates for talking are much lower than for medical procedures. But doctors say that without compensation, there is pressure to keep appointments short to squeeze in more patients.

“Not to be crass about this, you’re just giving that service away,” Rodgers said.

Discussing options

Recently, Hinterberger took time from other patients and his duties at Schuyler Hospital in Montour Falls, New York, to conduct end-of-life conversations in his frank, casual style.

He told Pennell that if she experienced severe pneumonia or a serious accident, doctors might consider putting her on a ventilator or inserting a feeding tube. She could stipulate that she wanted only pain relief, essentially instructing doctors to “just kiss me and tell me you love me,” he said. Or she could ask for short-term interventions in case “you perk back up.” Or she could indicate, “I want everything. Just do it, do it,” he said.

“The middle option,” she eventually decided.

When Janice Ryan, 89, a former protective services worker with a bone marrow disorder, said she wanted nothing “unless I can recover and feel wonderful,” Hinterberger gently suggested allowing doctors to try.

“Give the doc some options,” said her husband, Dick, a retired professor. She agreed, but added, “I want quality of life; I don’t want to just be a vegetable.”

Hinterberger spent 40 minutes with Helen Hurley, 83, whose lung disease requires her to use nasal tubes connected to an oxygen tank she carries in a flowered bag. Then she tired, asking to finish the discussion in future visits, “a little at a time.”

But Mary Ann Zebrowski, 75, a retired vineyard worker with diabetes and arrhythmia, had a lot to say. She described her husband’s collapse in 2008, saying she was glad he had been resuscitated, but felt pressured to agree to a feeding tube because a doctor said, “What are you trying to do, kill your husband?” She eventually decided to remove the tube and let him die.

She said she wanted no feeding tube for herself, but short trials of other measures. Afterward, she seemed relieved, saying, “I just don’t want to put my kids through having to make these decisions.”