Medicare patients will be encouraged to discuss advance care planning with their physicians more frequently under changes to billing codes.
Beginning in 2016, Medicare will authorize payments to doctors for counseling their clients about end-of-life care planning at several times. Previously, Medicare would only pay a doctor for this discussion at the time of the “Welcome to Medicare” visit, and often patients just becoming entitled to Medicare had not yet formed opinions.
This is part of the Obama administration’s strategy to create a “health system that results in better care, smarter spending and healthier people,” according to the Centers for Medicare and Medicaid Services. Medicare will now pay the doctor for annual discussions of end-of-life issues so that as patient’s situations change and their views mature, they can make better informed decisions.
The Kaiser Family Foundation reports that about 3/4 of the 2.5 million people who die each year are age 65 and older, and about 1/4 of all Medicare spending for health care takes place during the last year of life. My own practice suggests than many clients — both young and old — would prefer not to be subjected to discomforting and invasive medical procedures when there is no hope of a meaningful recovery. Moreover, there are specialized services available under Medicare’s hospice program that patients and their families feel is more appropriate; these services which are designed to make an incurably and terminally ill patient comfortable are sometimes seen as contradictory to the traditional medical goal of curing disease.
Advance care planning involves helping individuals learning about the health care options that are available for end-of-life care, determining which types of care best fit their personal wishes, sharing their wishes with family, friends, physicians and taking steps to implement their plans. Lawyers can assist with the “implementation” phase by writing documents, but experts state that frequently, beneficiaries may require a series of conversations with their physicians or other health professionals to clearly understand and define their end-of-life wishes so as to tell the lawyers what to write.
Studies have found that four out of 10 people older than 65 have not written down their wishes for end-of-life treatment. A number of years ago, Governor Ed Rendell vetoed a living will bill, encouraging the legislature to address this for Pennsylvanians. The legislature responded, and we now have a “default” decision-making framework for patients who do not have living wills. However, everyone agrees that it is better for a person to “stay out of trouble” by considering end of life issues and making his or her own decision, that to have to “get out of trouble” by using he Pennsylvania Health Care Representative Procedure.
The new CMS rule creates separate Medicare billing codes and provider reimbursement rates for advance care planning, and will allow physicians to include advance care planning as part of patient’s annual check-ups. Physicians are also reimbursed for such discussions that occur during a patient’s initial visit after enrolling in Medicare. For some time, the American Medical Association and others have recommended that physicians be authorized to provide and compensated for counseling in this area. According to CMS, the new rule will better enable seniors and other Medicare beneficiaries to make important decisions that give them control over the type of care they receive and when they receive it. For Medicare beneficiaries who choose to pursue it, advance care planning is a service that includes early conversations between patients and their practitioners, both before an illness progresses and during the course of treatment, to decide on the type of care that is right for them.
Of course, having a living will and getting it enforced are different. The Advisory Board Company, a health and education think tank, has promulgated a suggested strategy known as the “ABCDEs” of advance care planning for patients who are critically ill and may need to use their living wills.
Announce to the medical team that you have an advance directive.
Be clear to the medical team about your intentions for treatment.
Communicate and coordinate with family members to ensure everyone understands the treatment plan.
Discuss next steps.
Explore the benefits of palliative and/or hospice care.
Amos Goodall is a certified elder law attorney practicing in State College with Steinbacher, Stahl, Goodall & Yurchak. He is also a fellow of the American College of Trust and Estate Counsel and was recently listed by Best Lawyers as the 2015 Best Elder Lawyer in the Harrisburg area, which includes central Pennsylvania.