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Possible Health Policy Changes For End-Of-Life Discussion Between Patients And Physicians

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“Another possible change in health policy now, the Medicare system is considering starting to pay doctors for their time to they spend counseling patients about how they want their lives to end. Five years ago, you’ll remember the political blowup over what were then being called “Death Panels.” I asked Sound Medicine’s health policy analyst Dr. Aaron Carroll what has changed.”

Dr. Carroll: Probably just time to be honest. Before the passage to the Affordable Care Act, before those issues in 2008, this was a bipartisan supposed, non-controversial type of issue. The idea was that we want people to have conversations about how they would like to be cared for at the end of their life. Sometimes it’s not all about pulling the plug…. Or I just want my wishes to be honored. And it’s important for patients to know what different options are, to think through those issues, and then to have them documented correctly. Of course, few people are better equipped to have that conversation than their physician. The law, which was going to do what many states had already tried to do, was to start paying physicians for that consulting time, because time is money. So, just as it might pay physicians to talk about other diseases or to talk about health or to do other kinds of education and guidance, it was going to pay some nominal amount of money for physicians to spend time talking with Medicare patients about what they might like to have done to them at the end of their life.

Lewis: Surely, at least some doctors are already doing this sort of counseling. Is the difference just merely the money or do you think more time would be spent with this?

Dr. Carroll: The difference in terms of Medicare is the money, is that they would be paid for something they otherwise would have to do on their own dime. Of course, there are people who say, because the government is paying for it, it’s going to be more likely that doctors will be do it. And I think that’s absolutely true. But this is something that we want doctors to do. We want patients to have their wishes respected. It’s important to keep emphasizing that. This is not about talking to patients about when to withdrawal care. This is talking to patients about what they want done for them, by their own choice, at the end of their life. Sometimes it’s less, sometimes it’s more. What’s important is that we have the conversation and that the patient’s wishes are respected and followed.

Lewis: Would these sessions be mandatory?

Dr. Carroll: No. I mean, they would be paid for if they occurred, but there’s no sense of, you don’t get paid if you don’t do this thing. Now having said that, I can’t guarantee that Medicare policy or private insurance policy wouldn’t at some point in the future try to use this as some sort of quality metric to then see whether doctors should be paid more or less money. But at the moment, this is more offered as we’re going to pay doctors for their time when they do this counseling rather than, we’re going to penalize those who don’t. 

Lewis: How do patient implement the results of these conversations?

Dr. Carroll: Usually with some sort of living well.. that would say specifically what do you would want to happen to you if something were to go wrong. This is not something that is just for people who are elderly. I was recently checking in for a procedure not too long ago, and every time I go, they ask me if I have an advanced directive. The answer for me is yes. My wife and I both have advanced directives and living wills for what would happen in worst-case scenarios. And it’s important for people to have that type of document prepared in case something occurs. And it’s a good idea to discuss it with your physician so that your wishes are what happens.

Lewis: How common are advanced directives?

Dr. Carroll: I wish I could give you a number. I’m not exactly sure. They, however, are more common then they used to be… But it’s the kind of thing that everybody should have. 

Lewis: Do you know of any research that’s been done to the results of advanced directives, in terms of both cost-savings or patient-family satisfaction?

Dr. Carroll: Certainly, with respect to costs it’s a tricky subject. A lot of people will hold up advanced directors to reduce health care spending, but that of course believes that all advanced directives are about withholding care, while ignoring the fact that some advanced directives are about do everything humanly possible. Now there’s a widely held belief that physicians err on the side of doing things, but there’s still no real evidence for that at all. As for quality, there have probably been studies done to show how well people adhere to the advanced directives when they actually come into play. Unfortunately, that’s a very local thing. We don’t have a lot of national data. We can only say what certain physicians in certain areas have done. Nationally, we have no idea… It’s hard to figure out how this could result end in less satisfaction… People’s fear is that they somehow could be used for what patients don’t want. That’s the exact opposite. When they don’t exist, that’s when the risk of having something that you don’t want to happen. 

  • Dr. Aaron Carroll is a professor of pediatrics at the Indiana University School of Medicine. He blogs about health policy and research for The Incidental Economist and The Upshot