Physicians may soon be paid for end-of-life discussions

The American Medical Association (AMA) has submitted codes that could finally lead to Medicare reimbursement for end-of-life and advanced care conversations, five years after a previous effort was squashed when the talks were labeled “death panels.”

It’s now up to the Centers for Medicare and Medicaid Services (CMS) to decide whether to establish payment and cover the service. The answer is expected in November, when CMS releases its final 2015 physician fee schedule, according to the AMA.

The latest effort grew out of standard operating procedure as opposed to the ill-fated attempt in 2009 to provide for reimbursement under the Affordable Care Act (ACA), said the AMA.

That attempt went down in flames after Sarah Palin cast the discussions as “death panels” with authority to decide who should and shouldn’t receive end-of-life care.

Though the interpretation was discredited and termed “Lie of the Year” by PolitiFact, a blog published by the Tampa Bay Times, the death panel idea persists, with as many as 40% of Americans still believing it as late as 2013, according to a survey by the Kaiser Family Foundation. Partly as a result, a regulatory attempt in early 2011 that would have reimbursed for advance care planning discussions during annual wellness visits also failed, according to the New York Times.

To fill the void, three bills - S. 1439,  H.R. 1173, and S. 2240, have been introduced in the last two years that would all provide for Medicare reimbursement for advance planning discussions. But legislation won’t be necessary if CMS agrees this fall to accept the current procedural terminology (CPT) codes. The first is a 30-minute code for advanced care planning and the second is a 15-minute add-on code for additional time spent, the AMA told Medical Economics.

The AMA develops the codes for CMS to use to price physician services. Noting that in a typical year the AMA submits “hundreds of codes that are either new, revised or deleted,” CMS said in a written statement that it would now either:

• establish payment and cover the service as described by the code;

• not pay for the specific code but indicate that Medicare will cover the service as part of another code; or

• deny payment because Medicare does not cover the service.

CMS will accept comments from nursing homes, hospitals, and physician groups prior to making a decision.

The current push stems from a 2013 request by the Illinois State Medical Society to develop codes for advanced planning discussions, said the AMA. Insurance companies have already begun reimbursing for the discussions after developing their own Healthcare Common Procedure Code (HCPC) in the absence of a CPT code.

But the AMA notes that, because most seniors are insured by Medicare, those reimbursements would have a much wider impact. In 2011, almost 93% of Americans 65 and older were covered by some form of Medicare, according to the U.S. Department of Health and Human Services’ Administration on Aging.

The AMA is a longtime advocate of advanced planning discussions and wants to see physicians paid for them. Currently,  physicians report that they have to squeeze the discussions into unrelated visits or conduct them for free, according to the New York Times. 

The American College of Physicians, the largest medical specialty organization in the U.S., is also a proponent of the discussions and “encourages physicians to routinely raise advance planning with adult patients with decision making capacity and encourage them to review their values and preferences with their surrogates and family members,” according to its ethics manual. Both organizations say that those discussions are best done in an outpatient setting before an acute crisis occurs.

Read: End-of-life care comes to the forefront

As the population ages, experts predict more Americans will seek out physicians for advanced care planning including do-not-resuscitate orders, hospice information, and pain relief directives. In August 2013 the Care Planning Act (S. 1439) was introduced by Sen. Mark R. Warner (D-Va.) and Sen. Johnny Isakson (R-Ga.), to “…give people with serious illness the freedom to make more informed choices about their care, and the power to have those choices honored,” according to Warner’s office.

H.R. 1173 introduced in March 2013 by Rep. Earl Blumenauer (D-Ore.) would provide Medicare and Medicaid coverage for voluntary consultations between patients and their doctors about advance care planning, as well as ensure that an individual’s electronic health record is able to display any current advance directive.

In April, Senators Tom Coburn (R-OK) and Chris Coons (D-DE) introduced S. 2240, the Medicare Choices Empowerment and Protection Act, a bill to encourage Medicare beneficiaries to create advance directives.

Said Senator Coons in a press release: "Too many Americans leave their end-of-life care to chance or to the preferences of distraught family members. This bill will help more Americans ensure they are the ones making the choices about their end-of-life care, reducing confusion and empowering more Americans to spend their final days and hours on their own terms."