Medicare's Advanced Care Reimbursements a First Step

A palliative care specialist is hopeful that CMS will attach appropriate reimbursement to time physicians spend talking with patients about their wishes for end-of-life care. But don't expect it to save money, he says.

The Centers for Medicare and Medicaid Services this week unveiled a proposed rule change (p.246) that for the first time reimburses physicians and other providers for time spent with patients discussing end-of-life care.

R. Sean Morrison, MD, is a geriatrician and palliative medicine specialist at Icahn School of Medicine at Mount Sinai in New York, and director of the National Palliative Care Research Center. He spoke with HealthLeaders Media about the long-awaited rule, what it represents, and its potential ramifications. The following is an edited transcript.

HLM: The rule makes for dense reading. What does it say?

RSM: The new ruling says that for the first time doctors will be reimbursed for the time spent talking with patients about their wishes for care and treatment near the end of their lives.

Surprisingly, before the time this was put in, the time I spent talking to a patient about their values and goals, how would they like to be treated near the end of their lives, and how would they like to be treated in the setting of a serious illness, was not reimbursed by Medicare, even though it was a routine part of my practice.

It typically takes as little as 30 minutes, but sometimes up to an hour because these are intense discussions and I was never paid for it. What the new ruling says is now there is appropriate coding that when physicians take the time to talk to their patients about what their wishes are they will be appropriately reimbursed. It really is as simple as that.

HLM: Are these the conversations you have with your patients every day?

RSM: Every day.

HLM: Is there a dollar figure on the value of the reimbursements?

RSM: I don't know at this time. They haven't attached a payment to it.

HLM: Even if it doesn't cover your costs, is the reimbursement important symbolically?

RSM: It's important that they've acknowledged that this is an important part of the doctor/patient relationship. I am hopeful they will attach appropriate reimbursement to the recognition that this is a part of the routine care of patients and their families. A few commercial insurers have started to reimburse for this, and if this follows other patterns, [more] commercial insurers will reimburse for physician time for these conversations.

HLM: Why has this rule change taken so long?

RSM: That is a very good question. There are three reasons. The first is that under Medicare, for years and years, what we have valued and reimbursed is procedure-driven care and conversations have not been thought of as a procedure, when in fact they are.

The second thing is that people just don't realize or haven't realized how difficult it is to get the individual treatment in the setting of serious illness. It has only been the aging of the Baby Boomers, their parents moving into their 70s and 80s, that people have recognized we need to do a better job at providing care for people with serious illness and understanding their values and goals.

The third is that we have seen a change in how we as Americans view autonomy. Forty, 50, 60 years ago what the doctor said is what you did. The patient's voice wasn't present.

What we are seeing now, appropriately, is a recognition that people are different, that people have different values and different treatments need to be provided to meet those values and we need to do a better job respecting that autonomy. That has taken a long time to move forward.

HLM: Does this have significant financial implications for the healthcare system?

RSM: It actually doesn't, I'm afraid. There was a very good study by Ezekiel Emanuel that actually looked at the cost savings around this and the answer was probably not much. What it does mean is that patients hopefully will begin to receive the care they want. There is abundant data showing that patients don't want and don't receive treatment they do want because their families and their physicians don't know their values and goals and what treatments will meet those.

Hopefully, by opening up a window to these conversations, we won't be working in the dark. Will this save money? Probably not, and that shouldn't be the goal of it.

HLM: Why does this not save money?

RSM: Globally, overall, patient-centered care will save money. When we can reduce waste in the system and provide patients with the treatments that they desire, that will globally save the system some money. Will advanced care directives have a significant impact? In the absence of other system changes I am not sure it will.

HLM: Do you see this rule change as a work in progress that could be revised and improved in the coming years?

RSM: Absolutely this is a work in progress. This is the first step, but boy is it an important step!

HLM: Do you see any potential problems?

RSM: I hope this doesn't get reduced to a check list and not having the conversations. The first step is to recognize the conversation is important. The next step is to realize the conversation is of appropriate high quality so we understand our patients.

HLM: There is now a 60-day comment period and their rule change, presumably, goes into effect in January. How should you and others who care about this issue respond in the coming months?

RSM: We need to submit comments in support of this. We've already seen physician groups making comments that this is the right thing to do. What we didn't do well the first time around and what we need to do now is when people begin to talk about death panels and rationing, we need to be very clear and out front that this is not about that. This is about understanding our patients and respecting their choices and values.

HLM: It's political campaign season. Are you concerned that this rule change will revive talk about "death panels"?

RSM: We have to be very consistent that these conversations are not about limiting or rationing care. These conversations are about understanding our patients, their values and their goals and by doing that we can match treatments to those goals.

As physicians, we need to be crystal clear that these conversations are about understanding our patients better and working with them to provide the treatment they want and need, and that it is not about rationing care and it is clearly not about withholding treatments.

HLM: Do you think this could rise above the demagoguery?

RSM: I think it will. Serious illness affects people across the political spectrum. Tea Party Republicans want their values and choices respected and Progressive Democrats want their values and choices respected. I am hopeful that this will not be a political issue this time. The Affordable Care Act has been passed and upheld twice by the Supreme Court. I am optimistic that this rhetoric won't hit us again.