End-of-Life Counseling Sessions Stall despite Medicare Payment

May 03, 2016 - Starting in January 2016, the Centers for Medicare & Medicaid Services (CMS) began reimbursing physicians for conducting end-of-life and advanced care planning discussions with patients who are Medicare beneficiaries. Doctors are able to file $86 claims for performing end-of-life counseling sessions in the span of half an hour and CMS has not established specifically what needs to be covered during these discussions, Kaiser Health News reported.

Some of the typical topics include establishing advanced directives regarding life support measures as well as deciding on which friend or family member should be one’s healthcare proxy. The Medicare program will also reimburse nurse practitioners and physician assistants who partake in end-of-life counseling sessions, which can be completed during wellness visits or annual primary care check-ups.

While Medicare now reimburses doctors for conducting these discussions, the “Conversation Stopper: What’s Preventing Physicians from Talking with Patients about End-of-Life and Advance Care Planning?” survey shows that only 29 percent of physicians have had any formal training on covering end-of-life counseling sessions.

The survey was completed by the John A. Hartford Foundation, the California Health Care Foundation, and Cambia Health Foundation. The survey also illuminated that 24 percent of physicians did not have an area in their electronic health record to fill information regarding an advance care plan.

To learn more about the findings from this survey, HealthPayerIntelligence.com spoke with Dr. Terry Fulmer, President of The John A. Hartford Foundation. When asked about the most surprising finding from the survey, Fulmer replied, “I think, for me, it was learning how few physicians have really had any formal training. Less than a third - 29 percent - said they had any formal training on talking with patients and families about end-of-life care. I think that’s really quite remarkable. The good news is that’s something that we can address.”

Along with this finding Dr. Fulmer mentioned, the survey also discovered that 29 percent of physicians polled work in a medical practice or facility that has a “formal system” for addressing patients’ wishes and goals during end-of-life counseling sessions.

When asked about the reasons why the Medicare incentive to reimburse doctors for end-of-life discussions hasn’t worked, Fulmer answered, “We know that it’s only since January 2016 that Medicare began reimbursing physicians for these conversations. So we’re early in uptake and I think that’s why our numbers are so low. I think that with this new reimbursement, that even a year from now, we’ll see some change in that proportion.”

“Also, we’ll see systems working to update their electronic health records appropriately so that there is a place. We found that only four in 10 of the people surveyed said that there is no place in their record that indicates whether or not a patient had an advanced care plan or they were not sure. I think it’s early. I think we will see some momentum and I think that this is a wake-up call to say ‘Let’s make sure we got it in our electronic health record appropriately.’”

Along with the need to update electronic health record software to reflect end-of-life counseling sessions, 48 percent of doctors surveyed stated that they thought an advanced care planning discussion would make patients believe that their physician was “giving up” on their health. This perspective could have also played a role in preventing doctors from conducting end-of-life discussions despite Medicare reimbursement incentives.

“When you think about what physicians do as a calling - they are there to save people’s lives, to treat disease, and cure people. That is their job,” Fulmer clarified. “I think that as a society, we have to have a broader conversation, which is exactly this is doing. As a person, what would you want at the end of your life and how can we work as physician and patient together to make sure that you get the care that you do want, that you don’t get unnecessary care, and that we honor your wishes? That’s where we’re going.”

“Physicians are some of the most remarkable people that we have in our society and they are very devoted to meeting the needs of their patients. This is another way to help them do that. I say that as a practicing nurse with a lot of insight into watching this particular discipline physicians work every day.”

When asked what problems physicians are having when it comes following through with end-of-life counseling sessions and advanced care planning discussions, Fulmer explained, “You will find physicians say that time is an issue and so, therefore, this benefit is really, really important. When you survey physicians and you ask about some of the major barriers, they will tell you that the time to speak to someone is a barrier.”

“These are very sensitive topics and it’s not something that you’d want to bring up and then rush someone through. So time is very important. Therefore, this coverage will really allow people a very generous amount of time to talk to their patients in a way that is sensitive and complete.”