Medicare end-of-life counseling off to slow start

Dr. Tony Back

Dr. Tony Back

Older patients want to talk with their doctors about how they will die, but are doctors ready to have the conversation?

Medicare began reimbursing physicians in January for time spent discussing their patients’ end-of-life wishes. While 95 percent of U.S. physicians support the new benefit, only 14 percent say they have yet billed Medicare for advance planning patient visits, according to a survey of more than 700 U.S. doctors by three healthcare foundations.

The new Medicare policy aims to help people learn about their healthcare treatment options, determine the kind of care they want and share their wishes with family, friends and healthcare providers. An advance directive should be captured in writing, and entered into the patient’s electronic health record. The conversations can take place during a senior’s annual wellness checkup, or during counseling sessions in hospitals. Nurse practitioners and physician assistants also can be reimbursed for planning sessions. The Medicare benefit is not limited to a single conversation, or to patients close to death.

Older patients want to have these conversations – a poll last year by the Kaiser Family Foundation found that 80 percent like the idea. It is a sensible reform that can save Medicare money over time, because end-of-life discussions very likely will reduce healthcare costs. Roughly one-fourth of Medicare payments cover patients in their last year of life.

But the healthcare system is not ready to get this done on a large scale. Only 29 percent of doctors surveyed say their practices have formal systems in place for assessing end-of-life wishes. Forty percent say their electronic record systems do not include information on advance directives. Just 29 percent say they have had any formal training on end-of-life care, and 46 percent say they are not sure what to tell patients while having these conversations.

“It worries me that we have this big disconnect,” said Dr. Tony Back, co-director of the Cambia Palliative Care Center of Excellence and professor of medicine at the University of Washington in Seattle, referring to the healthcare system’s poor job of engaging with patients on end-of-life conversations. “If you are a patient with a serious illness, you cannot count on running into a doctor or nurse who can guide you through a conversation about what you want at the end of life.”

(The research was commissioned by the John A. Hartford Foundation, the California Health Care Foundation, and Cambia Health Foundation).


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