Nearly every day Dr. Dulce Cruz Oliver, a geriatrician at Saint Louis University, helps patients face death. She guides them through choices about the care they will receive in their final days. She asks about their desire to be kept alive by treatments such as artificial breathing machines and intravenous nutrition. She finds out whether they would prefer to receive care intended only to keep them comfortable as life fades, perhaps even in their own home.
Cruz and a nurse practitioner spend an average of eight hours over the course of three or four visits talking with a patient about what medical care they wish to receive, or forgo, during that time. She says the satisfaction of leading patients through those difficult but important conversations is one of the reasons she decided to be a geriatrician. But right now -- she receives no direct compensation for any of those conversations.
The U.S. Centers for Medicare and Medicaid Services recently proposed paying doctors such as Cruz for time they spend talking about the care patients wish to receive in their final days of life and drafting documents called advance directives to spell out their thoughts on life support, resuscitation and comfort care.
Medicare provides health insurance for 55 million people who are at least 65 years old and about 80 percent of Americans who die each year are insured by the program. Supporters of the new Medicare payment, including AARP and the American Medical Association say it will empower patients to book appointments to discuss end-of-life care and encourage doctors to make time for the discussions. Any program that increases the clipped and often hurried dialogue between doctors and patients has broad implications for the entire medical field, but detractors of the payments point out that a similar charge instated four years ago to foster discussions on obesity has failed to gain much traction.
A new paradigm of care
Doctors have increasingly subjected dying patients to a barrage of treatments, surgeries and medicines in the name of extending life. Prominent physicians and authors such as Dr. Atul Gawande have pointed out that this aggressive approach erodes any hope patients have of enjoying a decent quality of life in their final days. Two out of three Americans spend their final days in intensive care units or nursing homes even though most would prefer to die at home.
Critics say that new reality has prompted the need for physicians, patients and family members to openly discuss the question: what matters most to you in your final days?
“For so long, we have viewed death as the enemy and if you can't save someone's life, it's a failure,” Dr. Adam Schiavi, an anesthesiologist in the critical care division of The Johns Hopkins Hospital, says. “I think the most gracious and caring you can be is at the end of someone's life and how you manage that.”
Schiavi counsels many families on these decisions and says it is immensely helpful for doctors to have a written statement to guide a patient’s care. He estimates that about 30 percent of patients he treats have an advance directive. Among those that do not, about half have at least discussed their wishes with family.
Schiavi says the government can wield new Medicare payments as a tool, to prompt doctors to speak with patients about matters that the administration deems important for public health, or which have high cost-savings potential for government-run programs. For example, 28 percent of Medicare expenses were charged in the final six months of patients’ lives in 2011.
Already, a doctor can charge Medicare about $30 if they talk with patients about smoking cessation for at least 10 minutes and $20 for an annual 15-minute depression screening (exact rates depend on the location of the doctor or hospital). In 2011, Medicare added coverage for obesity counseling at a rate of about $30 for a 15-minute visit.
Selling a free service
However Dr. Scott Kahan, director of the National Center for Weight and Wellness, says the obesity service has seldom been used. Billing records showed that between 2011 and 2014, only 1 percent of Medicare patients received obesity counseling from a doctor even though about 30 percent of the program’s recipients were obese. If approved, could end-of-life counseling be destined for the same fate?
Dr. Richard Colgan, a primary care physician at University of Maryland School of Medicine, suspects it will, even though he supports the measure as a way to raise awareness about end-of-life conversations.
Kahan says most doctors still do not realize that they can bill for obesity counseling, even four years after the coverage was first announced. Similarly, most patients probably don’t know that they can sign up for free counseling with their doctor.
“I speak regularly to primary care doctors on obesity and I usually throw in the question, 'How many people know that Medicare covers obesity counseling?'" he says. “It's rare that a couple hands in a room of 50 or 100 go up.”
Dr. Phillip Rodgers, a primary care doctor in the University of Michigan Health System, says major medical organizations that pushed for the end-of-life counseling payment have pledged to educate members and the public of its existence, if approved.
Still, many practicing also do not have enough experience or training to comfortably provide obesity counseling to patients. Developing the soft skills to guide sensitive face-to-face conversations about obesity or death have only recently emerged as a focus within the field.
Cruz at Saint Louis University hires actors to visit her classes so students can practice discussing advance directives and life support. Colgan’s program at University of Maryland has taught these skills for the past 10 years. But many of today’s doctors missed out on this opportunity, so Cruz recommends offering continuing education courses on the topic, which every physician is required to take to renew their license.
Stuart Butler, an economic fellow at Brookings Institution, a nonprofit think tank, says reimbursement for end-of-life counseling is only a first step -- to be implemented alongside advanced training and awareness campaigns.
A fair price
Schiavi says low payment is another issue and believe Medicare should reimburse doctors for services such as obesity and end-of-life counseling at the same rate they would receive for performing other duties, if administrators really expect doctors to have these conversations.
As Rena Conti, a health economist at University of Chicago, says in an email, “chemotherapy generates revenue for physicians, not end of life care.”
Though the payment for end-of-life counseling has not yet been announced, experts say it will likely reflect the rate for obesity counseling. Medicare’s payment for a standard 15-minute visit is $73 -- far higher than the $30 reimbursement for a 15-minute obesity consultation.
“Virtually every doctor I speak to who is aware of the Medicare benefit really has a problem with the paltry level of reimbursement,” Kahan says.
Cruz suggests a charge of between $40 and $60 for end-of-life counseling would be more appropriate.
“Doing this is hard work,” she says. “It's as hard as any other type of procedure.”
Medicare itself has requested feedback on whether end-of-life counseling (called “advance care planning services” in the official proposal) should simply be covered as part of an annual wellness visit, for which doctors bill the program about $120.
Schiavi at Johns Hopkins says reimbursement for end-of-life counseling is an important step regardless of what the final rate may be and even if it’s not a perfect solution.
“I'm not saying it's the answer but it's an answer and they've got to do something,” he says.