“It is one thing genuinely to determine what people’s treatment wishes are, but the danger is very grave that efforts to pay for advance care planning sessions (under) Medicare will turn into subtle efforts to pressure some of the most vulnerable patients to surrender their right to live,” Balch said.
Like the current proposal, the provision that sparked controversy in 2009 would have provided Medicare reimbursement to doctors who used office time to discuss living wills, advance care planning or other matters pertaining to patients’ end-of-life preferences. It did not require such conversations, but ensured that doctors or other practitioners would be compensated for these often difficult sessions.
Then Sarah Palin weighed in. “The America I know and love,” she wrote in a now infamous Facebook post, “is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care.”
“Such a system is downright evil,” she wrote.
Whether it was a willful misrepresentation of the actual proposal or a misreading of it — PolitiFact, a fact-checking operation run by the Tampa Bay Times, described Palin’s posting as the “Lie of the Year” — Palin’s broadside ignited an outpouring of criticism on conservative media. Other Republicans, including then-House Republican leader John Boehner, picked up the refrain. “This provision may start us down a treacherous path toward government-encouraged euthanasia if enacted into law,” he said.
It wasn’t long before the provision was scrubbed from the bill. Two years later, the administration proposed a similar measure through regulation but withdrew it out of fear of sparking another controversy.
The current effort began last year, when the Illinois State Medical Society recommended that the AMA adopt specific medical codes for the reimbursement of doctors for advance care conversations. Medical codes provide a uniform description of hundreds of medical procedures and services and are used by medical providers, hospitals and insurers across the country. In response to the Illinois request, an AMA panel approved a new code for advance planning.
In the absence of a code, doctors who want to have such conversations with their patients have had to squeeze them into medical appointments ostensibly held for another purpose. Many providers say that forces them to give short shrift to a discussion intended to help a patient — and often, family members — understand all the medical options and the risks associated with each one. Those sessions take time and delicacy, doctors say, and shouldn’t have to be fitted in among other medical procedures or exams.
“It may take up to two hours to bring everyone to an understanding of the situation and the various options,” said Thomas J. Smith, an oncologist and director of palliative care at Johns Hopkins Medicine.
Furthermore, there is no current reimbursement for phone consultations, for instance with relatives who don’t live in the area. It’s also not easy to get reimbursement for patients who are well but still want to discuss advance directives.
“You essentially have to be deceitful to get paid to do advance care planning for the patient who doesn’t have a medical illness,” said Christopher A. Jones, an assistant professor of palliative care at Duke University.
“The federal government places no value on this conversation. None,” said U.S. Rep. Earl Blumenauer of Oregon, a Democrat who is sponsoring a bill that would require reimbursement for advance care planning.
“If reimbursement occurs at all in the federal program, it’s incidental to the primary treatment or somebody miscodes, and that’s not the way it should be,” Blumenauer said. “Under the best of circumstances, this is a difficult conversation for both doctors and families alike that takes time and focused attention.”
The lack of compensation for advance care discussions is part of a broader pattern: Doctors who perform procedures, such as surgeons, generally are paid more than those who examine and counsel, such a geriatricians and internists. Studies consistently show that the compensation for “proceduralists“ is three times or more higher than that of primary care doctors and others whose practices usually involve diagnosis and noninvasive treatment.
In Congress, Blumenauer is hopeful his bill will get a hearing free of any death panel outcry. It helps, he said, that among his 30 co-sponsors are a number of Republicans, all of whom oppose the ACA.
“They know this is not about the ACA at all,” Blumenauer said by phone from Oregon. “I don’t care if you’re for the ACA or against it or don’t care one way or the other. This is legislation that is supported by 90 percent of the public.”
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