Sunday, August 31, 2014

A story by Pam Belluck in the New York Times left me with mixed feelings.  Here's an excerpt:

Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans. Some states, including Colorado and Oregon, recently began covering the sessions for Medicaid patients.

Who can doubt that such conversations are useful, helpful, humane, and more? But do we really need to pay doctors for them? And if so, how should such payments be structured?  The story goes on:

But the impact would depend on how much doctors were paid, the allowed frequency of conversations, whether psychologists or other nonphysicians could conduct them, and whether the conversations must be in person or could include phone calls with long-distance family members. Paying for only one session and completion of advance directives would have limited value, experts said.

“This notion that somehow a single conversation and the completion of a document is really an important intervention to the outcome of care is, I think, a legal illusion,” said Dr. Diane E. Meier, director of the Center to Advance Palliative Care. “It has to be a series of recurring conversations over years.”

Let's think this through. First, is such a payment--or set of payments--consistent with what many argue is the overall direction of health care payments, i.e., a capitated or global payment environment, or bundled payments for acute or long-term diseases?  By definition, no. Why are we thinking about adding a new fee-for-service billing code if the trend is away from that?

Second, is it all really necessary anyway?  I look at the experience of Gundersen-Lutheran Hospital in Wisconsin, which put in place a series of end-of-life discussion with their patients.  As I noted in this blog post over two years ago [emphasis added]:

Here’s the real lesson.  If we view things in this manner, any place in the world can do it.  It does not depend on new government policy.  It does not depend on a change in payment methodology.  It does not depend on accreditation rules and regulations.  The power to make these kind of change resides in the people who have been given the privilege and responsibility of running our health care institutions.

In short, the necessary condition for this kind of approach to be adopted is the support of executive and governance leaders.  That leadership often is based on a remarkably simple set of values, tied to a clear sense of institutional purpose.

As noted by Gundersen Lutheran CEO Jeff Thompson:

Why we pressed down this path has everything to do with the well-being of patients, families, and the health professionals who care for them. It is to preemptively answer the question, “What would your parent, your spouse, your loved one want in this situation?”  The purpose is to avoid anyone needing to say, “We wish we knew.”

As stated in the book, Having Your Own Say:

This breakthrough is not a new drug or test or treatment; it is a new way to organize our care of patients with advance illness so that they can live as well as possible for as long as possible in the way of their own choosing.  The “miracle” is that this new care depends more on human interaction and coordination than on technology and science.  The wonder is that it costs less to deliver but is actually better.


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