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CMS Weighs Expanding Payment for End-of-Life Planning

By Kerry Young, CQ Roll Call

March 20, 2015 -- Medicare officials may this year propose creating a new payment for time that doctors spend helping their patients plan for how they would confront terminal illness and rapid declines in health.

Patrick H. Conway, the chief medical officer for the Centers for Medicare and Medicaid Services (CMS), gave an update on this work last week at an Institute of Medicine (IOM) conference on end-of-life planning. CMS last year rejected a request from the American Medical Association to create a new billing code, but clearly signaled an interest in looking further at this proposal as part of a future rule on payments for doctors.

"In this year's rulemaking, we will be considering whether to propose that code and whether there will be a payment for that code," Conway said, adding that he couldn't comment further.

Many doctors and lawmakers are pressing to incorporate end-of-life counseling into routine medical practice in the United States, moving beyond the limited discussion now covered as part of the wide-ranging "Welcome to Medicare" visit. The approach came under fire during the debate leading to enactment of the 2010 health law (PL 111-148, PL 111-152), with critics portraying it as a government effort to establish "death panels."

Advocates for end-of-life planning say a lack of planning can lead people to suffer through needless treatments and long hospital stays when they might prefer to spend more time at home. Noted surgeon and author Atul Gawande pointed out at the meeting that the week in which people in the United States are most likely to undergo surgery is the last week of their life. Without advanced consideration, the wishes of the dying person can be overlooked in a hurried chain of discussions about their care, with family members often flying in from all over the country to attend a loved one, he said.

"There's been no plan and no discussion," he said.

While CMS' rulemaking may provide the most direct path for expanding end-of-life planning among elderly Americans, lawmakers also are weighing action. Sen. Susan Collins, R-Maine, and Mark Warner, D-Va., addressed the IOM meeting early in the day. Collins had helped get the advanced directive discussion included in the Welcome to Medicare visit.

"Many people nearing the end of life may not be physically or cognitively capable of making their own decisions about care," Collins said in remarks prepared for the IOM meeting. "Moreover, some of these patients will, at some point, receive acute hospital care from physicians who do not know them or their families."

Warner is likely to reintroduce a measure that he offered in the last session of Congress, a bill developed with Sen. Johnny Isakson, R-Ga., that would create a Medicare and Medicaid benefit for end-of-life planning. Speaking at the Institute of Medicine (IOM) meeting last week, Warner recalled how that even families with access to good medical information now struggle when confronting with terminal illnesses, as happened in his own mother's fight with Alzheimer's disease. After her initial diagnosis, his family didn't discuss living wills and advanced care directives or what his mother wanted in her final years.

"I was an informed citizen at the time - the governor of Virginia - and yet my family and I didn't have a full understanding of everything that was before us," Warner said. "With more information and support, we could have been able to hold important family discussions with my mother, worked with her doctors and pastor to craft a care plan that truly reflected her wishes."

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