The Obama administration plans to pay doctors to hold end-of-life planning conversations with patients, a controversial decision that will almost certainly revive the "death panel" debate that has long dogged the Affordable Care Act.
Medicare rolled out new rules Wednesday (on page 246 of this document) that would reimburse physicians who talk to elderly patients about what options are available at the end of life — whether they would want life support, for example, or whether hospice care would be of interest. Doctors would get paid, under these new rules, for helping patients complete an advance directive.
The reimbursements would begin in 2016.
Health-care experts near universally agree that these conversations are important. But right now, most Americans don't have advance care directives that explain what type of treatment they'd like. That leaves families to make heart-wrenching decisions on their behalf.
At the same time, the White House has found the issue politically toxic and repeatedly backed off plans to move forward. It nixed a provision in Obamacare that would pay doctors for explaining "the continuum of end-of-life services" after it became the center of an ugly skirmish over whether Obama wanted to "pull the plug on Grandma."
The Obama administration then attempted to quietly set up such a payment system through regulations, like the ones proposed today. But after a front-page New York Times story drew attention to the decision, Medicare backed off and once again dropped the issue.
This all makes today's decision an especially big step: It's the Obama administration saying they think these conversations are important, and want to move forward on them regardless of an inevitable political blowback.
What exactly are Medicare doctors getting paid to do?
End-of-life care planning is not currently a routine part of medical care in the United States. Most surveys show that about a quarter of American adults have completed an advance directive, spelling out what type of treatment they would want in a medical crisis where they could no longer make their wishes known.
Americans don't plan for death because health insurance plans — including Medicare, which covers nearly 50 million Americans over 65 — don't typically pay for that sort of planning, the way they cover blood tests or MRI scans.
The dearth of end-of-life care planning in the United States often means that lives end in chaos, with families confused and overwhelmed trying to think through what their loved ones would want.
The Obama administration's new rules will reimburse doctors for having an end-of-life care consultation with Medicare patients — a conversation in which a doctor would tell a patient about his or her options.
The new rules say doctors can get paid for "advance care planning including the explanation and discussion of advance directives." They also outline what a sample conversation might look like:
This could occur in conjunction with the management or treatment of a patient's current condition, such as a 68 year old male with heart failure and diabetes on multiple medications seen by his physician for the evaluation and management of these two diseases, including adjusting medications as appropriate.
In addition to discussing the patient's short-term treatment options, the patient expresses interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient's desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity.
This type of planning would likely include discussions about whether the patient would prefer to die in the hospital or at home. The doctor would not make the decisions for the patient — the patient and family would make up their own minds about how to proceed.
Why do people oppose this?
The fear at the heart of the death panel debate was a fear about the loss of autonomy: that a group of anonymous bureaucrats would make the decisions that ought to be reserved for the terminally ill.
Obamacare opponents worried that doctors would use these conversations to recommend less expensive care that costs the government less — and shortchanges the patient.
Part of these fears are based on misinformation: Neither the Affordable Care Act nor these new regulations will let any government panel decide what end-of-life care is or isn't appropriate for patient.
Patients, meanwhile, face a different and very significant loss of autonomy when they don't have these conversations. They don't get to decide what type of death they want, what goals will be important to them, and what type of life-sustaining treatment they'd prefer.
"It's one of the most uncomfortable things," says Donn Dexter, a neurologist in Eau Claire, Wisconsin, who works on end-of-life planning. "The family can be so at odds, and the patient has not made clear what they want. I've seen families just torn apart by this, and their loved ones tortured with prolonged, futile treatment at the end of life."
Unarticulated end-of-life decisions get outsourced to family members and doctors, who make their best guess at what a loved one would have wanted. Without advance care planning, patients end up living a version of the scenario that the death panel rhetoric made so fearsome: giving over decisions about their last moments of life to another party.
The aim of these discussions, then, is to make sure that end-of-life care wishes do get articulated — and that doctors have a financial incentive to take the time to make that happen.
Health care experts generally support this type of planning, to ensure that patients get the type of care they want, even when they are incapable of articulating their own decisions at the time. A Medicare spokesperson notes that the agency received 200 comments on the idea of paying for these consultations — and 199 were in favor of the idea.