Hospitalists care for patients with the most serious, chronic, and complex illnesses. As a result, they are often faced with the daunting task of counseling their patients to help them clearly define their end-of-life wishes. The mere subject of death is met with apprehension and avoidance, but its inevitability warrants an early discussion.
End-of-life care, also known as Advance Care Planning (ACP), enables patients to formulate advanced directives: a living will, the designation of a healthcare proxy, Medical Orders for Life-Sustaining Treatment (MOLST), and the preparation for hospice care, among others. Patients should start thinking about their healthcare options and share such important decisions with their physicians and family before the need for hospitalization.
On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released the final payment rules for Medicare reimbursement of physicians who consult with their patients on advance care planning. This separate payment system under the 2016 Physician Fee Schedule will impact the almost 55 million Medicare beneficiaries and their healthcare providers.
Effective January 1, 2016, Medicare will pay $86 for 30 minutes of ACP in a physician’s office and will pay $80 for the same service in a hospital (CPT billing code 99497). In both settings, Medicare will pay up to $75 for 30 additional minutes of consultation (add-on CPT billing code 99498). Such counseling can take place during a senior’s annual wellness visit or during a routine office visit and at various stages of health, always “at the discretion of the beneficiary.”
Six years ago, proposed legislation on Medicare reimbursement for ACP under the Accountable Care Act (ACA) sparked political debate over fears that the implementation of so-called “death panels” could influence decisions to avoid medical care. The goal was to reduce healthcare costs, but these controversial provisions were dropped with the passage of the ACA. This time, there was less resistance.
Proponents of this new legislation, such as the American Medical Association and the American Academy of Palliative and Hospice Medicine, say that this rule will encourage physicians to make time for these lengthy discussions and facilitate patient choices while improving quality of care for seniors. Opponents, including the Association of American Physicians and Surgeons, contend that such payments will “create financial incentives to persuade patients to consent to the denial of care.”
Patrick Conway, MD, CMS' chief medical officer, told the New York Times, "We received overwhelmingly positive comments about the importance of these conversations between physicians and patients. We know that many patients and families want to have these discussions."
Future endeavors should focus on efforts to improve the quality of delivering end-of-life care that honors and upholds a patient’s wishes. Strengthening the clinical training of physicians in palliative care, developing quality metrics and standards, and educating the public should remain a top priority.
Will tying a financial incentive to these services have an impact on the cost and quality of care delivered? Hospitalists can begin billing for valuable services they are already providing on a daily basis, and can better coordinate inpatient medical care when more seniors have clear advanced directives. TH
Dr. Zeitoun is a member of Team Hospitalist.