We may be about to have a new debate over “death panels.” If we do, it would be a tragedy for tens of millions of Americans and their families.
You may remember this small piece of the Affordable Care Act that garnered outsized attention back in 2010. It allowed Medicare to pay physicians for having end-of-life conversations with their patients. The program, which the Obama Administration delayed for years in the face of conservative political pressure, finally came on line last year. And Kaiser Health News reports that it is catching on more quickly than expected.
KHN reported that nearly 14,000 docs billed Medicare for end-of-life discussions with 223,000 patients in the first six months of last year. Medicare paid about $16 million for the work. Physicians got $86 for an initial conversation and $75 for additional discussions.
The idea: Docs would be paid for taking the time to talk to seniors about advance planning options. Ideally, these conversations would occur long before patients had to make end-of-life decisions. They’d simply be a way for physicians to encourage their patients to explore options, learn about how to make choices, and help them describe those decisions in legal documents. And remember, these conversations are completely voluntary. If a patient does not want to talk, nothing in the law requires him to. If a physician somehow feels the conversation would conflict with her personal or religious views, she does not have to have it.
In a 2015 survey, nearly 9 in 10 people backed the idea, though only one-in six said they had talked with their doctors about end-of-life issues. Only about one-third of those 75 or older said they had.
Yet, despite overwhelming public support for the idea, some lawmakers have strongly opposed it. In an effort to derail the ACA bill in 2010, Sarah Palin and others denounced these voluntary meetings as “death panels.” They suggested, with absolutely no evidence to support their claims, that doctors would pressure patients to forego aggressive medical treatment in old age.
Now, Rep. Steve King (R-IA) has introduced legislation that would bar Medicare payments for end-of-life discussions. King’s bill has no chance of passing on its own, but with the entire ACA up for grabs over the next several months, his proposal could sneak its way into whatever replacement Congress finally agrees to.
This would be a bad idea for many reasons:
At least 40 states (including King’s Iowa) have what are called MOLST or POLST forms. These are medical orders signed by physicians that describe a patient’s end-of-life wishes. In many states they are required for those who are hospitalized or receiving care in a skilled nursing facility. But they work best if a physician already knows how her patient wants to be treated if, say, her heart stops or she needs help breathing. The best way for that to happen is through a conversation long before a medical crisis occurs.
Too often, hospital-based doctors must fill out these forms for patients they do not know. The easiest way to encourage docs to talk to their patients long before the crisis hits is to pay for their time.
A modest fee may also encourage physicians to improve their communications skills so they can do a better job with this kind of talk. For many complex reasons, physicians often are not good at it. But with training and practice they can become much better. And that benefits them and their patients.
Finally, even modest compensation encourages docs to nudge their patients to talk about their end-of-life choices. Often patients want to, but don’t know how to start. A small push from a trusted doc may be all it takes.
With health care policy completely up in the air, this may seem like a small issue. But for millions of American and their families at the end of life, it can be the difference between a good death and a prolonged and painful one.