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A wise step: Medicare to pay doctors for end-of-life counseling

Stuart M Butler

In a proposed regulation announced on July 8th the Medicare program plans to reimburse physicians for their time spent in conversations with patients about how and whether they wish to be kept alive if they become too sick to express their wishes. Today physicians can only receive payment under Medicare if such conversations are part of a routine annual wellness examination.

This is a welcome proposal, and reflects a growing recognition among Americans that the health system too easily goes on autopilot, undertaking invasive procedures that often do little to improve the quality of a patient’s life. This is particularly troubling for many families when a loved one reaches the final weeks of life and there is uncertainty or disputes about the patient’s wishes. Physician-authors like Atul Gawande have drawn attention to the “overmedicalization” of dying. The National Academy of Medicine (formerly the Institute of Medicine) is one of many medical research bodies that have examined the issue. And organizations such as AARP have been raising the importance of families and their physicians discussing end-of-life options and making appropriate plans to have wished known and honored.

For physicians in many specialties, the need for lengthy conversations about end-of-life is rare and can be part of a regular examination. But for geriatricians, oncologists and others who have many elderly Medicare patients, there is a greater need for such conversations with patients and their families. Doing that properly takes time, and so it makes sense for physicians to be able to take that time without losing money under Medicare’s reimbursement system. The proposed new regulation would address that financial issue.

The proposal may re-ignite the “death panel” cries when a similar Medicare reimbursement was included in early drafts of the Affordable Care Act legislation in 2009 – unwisely identified as a budgetary “pay for” to help cover the cost of new coverage. That political furor set back what should have been a reasoned conversation. Hopefully the climate now is more open to careful consideration.

To be sure, while providing reimbursement is an important step, it is not enough. As Gawande notes, physicians typically are very poorly trained in how to have these difficult conversations with their patients, and often do not convey the quality of life considerations in ways that their patients and their families can fully understand. That problem needs to be addressed by medical schools and by better professional training after medical school. But by removing the financial disincentives for physicians to devote time to such conversations, the proposed change in Medicare payments is a good beginning.

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