Physicians are now reimbursed for end-of-life talks, but most still avoid the conversation. Formal training and systems may go a long way toward making advance care planning not just best practice, but standard practice.
Since Jan. 1, 2016, physicians have been able to bill Medicare for time spent discussing patients' wishes and goals for end-of-life care. Unfortunately, though most physicians say they support advanced planning conversations, most physicians avoid them.
Despite the silly talk of "death panels" and other empty political controversies surrounding advance-care planning when the Congress was debating the Affordable Care Act, physicians' associations overwhelmingly supported the historic provision in the Centers for Medicare & Medicaid Services (CMS) 2016 final rule allowing payment for these conversations.
As of early spring, however, only 14% of a national sample of physicians who regularly see patients age 65 and older had conducted and billed for these talks, according to a poll jointly released by the John A. Hartford Foundation, the California Health Care Foundation, and the Cambia Foundation. Representatives from the three organizations presented their results during an April 14 webinar.
This research is a rare attempt to quantify physicians', rather than patients', personal motivations and concerns surrounding the issue. "It is a pretty big investment to do a survey of physicians if you want to do it right and with robust methodology which we did," says Tressa Undem, a partner at PerryUndem Research/Communication. "This is not the type of survey you see every day."
Tony Back, MD, co-director of the University of Washington's Cambia Palliative Care Center of Excellence and executive director of Vital Talk, says a key takeaway from the study is the "huge disconnect" between the beliefs and actions of the same 736 physicians who said conversations about advance care planning were important (99%) and that it was their responsibility (75%), and not a family member's or another clinician's.
Barriers to end-of-life conversations identified in the study included:
- Lack of time amidst competing priorities
- Disagreements between patients and their families
- Uncertainty about when to broach the subject
- Fear of discomfort
- Concern the conversation would be conflated with giving up
Training Is Paramount
Back said that the results pointed mostly to physicians' reluctance to engage in these challenging conversations.
"Those [barriers], to me, are proxies of lack of skill," he says. "The physician hasn't learned that you can break up the conversation into little chunks… how to deal with families who don't agree… [how to] deal with the issue of whether the time is right, because actually, the time is never right."
These difficulties can be diminished with training, but only 29% of the physicians surveyed have received training. The minority of physicians who've had formal training in advance care planning and end-of-life talks are the ones more likely to conduct them.
Moreover, physicians who report having explicit training in end-of-life conversations are more likely (46%) to find conversations about end-of-life care to be rewarding than those who have not (30%), and also say they feel unsure about what to say in these conversations "rarely or not too often" (60%), compared to those who have not had explicit training (52%).
Physicians who have had such talks with their own doctors also appear to be significantly more comfortable with conducting them, according to the data.
"I think what that means is that even as a physician, you realize more clearly when you've done it yourself that you actually can do it with a patient and it won't be harmful, that you will get through it, and that actually there's some real benefit to it," Back says.
Debra Shute is the Senior Physicians Editor for HealthLeaders Media.