Hey Hospitalists, Let’s Have a Conversation about “The Conversation”

By  |  July 17, 2015 | 

by Howard Epstein, MD, FHM

Last week, the Center for Medicare and Medicaid Services (CMS) – the nation’s largest payer of healthcare services and the 800 pound gorilla in setting medical necessity and coverage policies – announced a proposal to begin paying for goals of care and advance care planning (ACP) discussions between medical providers and patients. Sound familiar? It should. This is the same, seemingly no-brainer proposal that in 2009 was stricken from the eventually approved Patient Protection and Affordable Care Act (PPACA, AKA the ACA, AKA “Obamacare”) in response to the intentional and patently false accusations of government run “death panels” in the hopes of salvaging some measure of bipartisan support. As we all know, the bill eventually passed the following year without a single Republican voting in favor in either the House or Senate – and without funding for ACP sessions!

This is not the first attempt to resurrect CMS funding for ACPs since its omission from the ACA.

In 2013, Oregon Congressman Earl Blumenauer – a champion of ACP and end of life (EOL) care on Capitol Hill – introduced a bill that would not only provide for reimbursement for ACPs, but also the development of supportive programs, including the storage and display of advance directives and physician orders for life sustaining treatment (POLST) on certified electronic health record technology (CEHRT). (While SHM strongly supported the concept of electronic access to the details of end of life plans, there were reservations at the time about EHR interoperability and the capability of storing and transmitting the most up-to-date information regarding patients’ wishes.)

In the Physician Fee Schedule Final Rule for 2015, CMS only considered whether or not to reimburse providers for these ACP consultations in the future, citing a need for more time to go “through notice and comment rulemaking” on the subject. SHM, along with 65 other medical specialty and professional societies, patient advocacy groups and other organizations submitted a joint letter on May 12, 2015 to then interim Health and Human Services (HHS) Secretary Sylvia Burwell to reconsider that decision.

Since then, SHM’s Public Policy Committee has continued to advocate for reconsideration. This issue is so critically important for the care of our hospitalized patients that it was a major topic of conversation during a meeting with the lead healthcare staffers for Medicare and Medicaid for the House Ways and Means Committee during Hospitalist on the Hill this past May – right up there with the SGR “doc fix”, the 2-midnight rule and observation status.

So, as Bugs Bunny might say, “Ehhhh, what’s all the hubbub about…bub?”

More than 2.5 million people die in the United States each year, most of them from progressive health conditions as published in the New England Journal of Medicine (NEJM). A 2010 study in the NEJM found that more than one in four elderly Americans lacked the capacity to make their own medical care decisions at the end of life. Under such circumstances, care decisions fall to family members and doctors who may not know the treatment preferences of the elderly patient. However, elderly patients with advance directives, have a much better chance of receiving the care that they wish.

According to the seminal SUPPORT trial published way back in 1995, 90% of Americans expressed a preference to die in their own homes, surrounded by loved ones in peace, comfort and dignity in familiar surroundings. Yet, 75% of us die in an institution – 50% in the hospital setting, and 25 % in a care facility. (This figure sadly hasn’t changed much in the past 20 years!) There’s also a preponderance of evidence that the hospital is an enormous source of suffering for patients and families facing serious, life-threatening or life-limiting illness. This includes physical suffering, such as pain, dyspnea and confusion. This situation also causes significant psychological, emotional, spiritual and even financial distress. Evidence demonstrates that advance care planning and end-of-life discussions reduce stress, anxiety, and depression in surviving relatives.

Published, peer reviewed research shows that ACP leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression and lost productivity. ACP is particularly important for Medicare beneficiaries because many have multiple chronic illnesses, receive care at home from family and other caregivers, and their children and other family members are often involved in making medical decisions.

ACP has become a standard of care, and consensus regarding its value is widespread. The 2014 Institute of Medicine (IOM) report “Dying in America” cited payment for ACP as one of its five key recommendations. The report states that “payers and health care delivery organizations should adopt these standards and their supporting processes, and integrate them into assessments, care plans and the reporting of health care quality.” The Centers for Disease Control and Prevention (CDC) has also advocated for increased use of ACP.

The need for ACP and access to primary and specialty palliative care is so great and accepted in the healthcare community. In their Choosing Wisely recommendations, numerous medical specialty societies, including ACEP, AAHPM, AGS and AMDA, have included early and reliable access to palliative care and avoidance of non-value added care, such as placement of feeding tubes in patients with advanced dementia, calling out the gap between quality, evidence-based, patient and family-centered care and “usual care” (e.g. medical and disease-focused care) that patients receive too often near the end of life.

So where’s the disconnect between what people want and what actually happens to them at end of life?

The answer is clear – we’re not having “The Conversation.” And, though our primary care and even specialty care colleagues are involved regularly in the care of these patients, they may be inclined to postpone or avoid ACP with patients and families in the outpatient setting due to lack of comfort, skill or even recognizing that the person they’ve been trying valiantly to cure or at least prolong the inevitable is on that down-slope of life we all eventually experience – it’s called “dying.”

Our current reimbursement system throws another barrier in front of providers. Like many other “non-procedural” activities, ACP is not only undervalued, there is currently a lack of value assigned to this important cognitive, empathic and communication-based “procedure.” And I refer to it as a “procedure” because like a surgical or invasive vascular procedure, when it goes badly, the consequences and sequelae can be just as damaging, and even irreparable.

Thus, intentional or not, the can is kicked further down the proverbial road until the patient reaches the hospital in a state of crisis – sometimes in extremis – and the hospitalist is left to make sense of all the clinical, emotional, psychological, spiritual and frequently familial history (baggage?) leading up to that hospital admission. We are expected to develop instant rapport and trust while simultaneously attempting to develop – in collaboration with our specialty care providers and, preferably, the patient’s primary care provider – a plan of care that takes into account the personal values and treatment preferences for that individual within the clinical realities of the patient’s illness and disease trajectory as they lie before us. Sound familiar?

In addition to providing primary attending, consultation and co-management services in acute care hospitals, hospitalists are increasingly found in post-acute care facilities, in which a large number of Medicare beneficiaries receive care. Hospitalists are critical team leaders for coordinating care, often being highly involved in the end of life care for patients. They are at the front lines of these conversations, often being asked to help patients plan for their end of life care needs and then ensuring that the system is set up to meet those needs. Many of their patients are acutely ill and often face these critical decisions in real time.

Thus, too often, hospitalists participate in end of life care conversations that are long overdue, which increases uncertainty and adds further stress to patients and their families at a time when they are most vulnerable.

So, here’s what all the hubbub surrounding last week’s CMS proposal is about:

Medicare, the federal program that insures 55 million older and disabled Americans and the 80% of Americans that die each year, announced plans July 8th to reimburse doctors for ACP conversations with patients and families. Dr. Patrick Conway, Pediatric hospitalist, Master in Hospital Medicine, and chief medical officer for CMS which administers Medicare stated, “We think that today’s proposal supports individuals and families who wish to have the opportunity to discuss advance care planning with their physician and care team. We think those discussions are an important part of patient- and family-centered care.” The plan as proposed would also provide for our allied health professional colleagues, such as nurse practitioners and physician assistants, to be reimbursed for face-to-face meetings with a patient and any relatives or caregivers the patient wants to include. The proposal in its current formulation does not limit the number of conversations reimbursed, recognizing that ACP is not a piece of paper to complete, but a process that occurs over time and as clinical realities unfold through the patient’s experience.

So how do we align the hospital, hospitalist, patient and payer to ensure that we are appropriately allocating resources to the important ACP procedure to provide the best quality patient- and family-centered care?

The American Medical Association (AMA) through the Current Procedural Terminology (CPT) Editorial Panel developed two new codes – 99497 and 99498 – that describe complex ACP. These codes were carefully considered and crafted by physician representatives of interested medical societies, as part of the AMA’s CPT process. This process included the opportunity for input from caregivers and other providers. Complex ACP involves one or more meeting(s), lasting 30 minutes or more, during which the patient’s values and preferences are discussed and documented, and used to guide decisions regarding future care for serious illnesses. These consultations are voluntary on the part of the patient and the patient’s preferences are paramount. The patient may choose to include his/her family, caregiver (if applicable) in the decision making process.

Making separate payment for ACP will not only promote these services for beneficiaries, but will also allow Medicare to track how these services are being furnished and to assess their impact on the quality of life and effectiveness of care. Programs like the physician quality reporting system already ask physicians to report on whether or not they did advance care planning with patients. Payment for this service will align with these quality reporting mechanisms and promote higher quality and value in the system.

So, to summarize why hospitalists should support this CMS proposal, the hospital is:

  • Where the most severely ill patients are
  • Where the greatest amount of unwanted suffering occurs
  • Where many critical treatment decisions are made
  • Where the most money is being spent, often not toward achieving patient or family care goals, and
  • The best place to plan for the next phase in the care continuum.

 A Call to Action for Hospitalists:  A final decision on the proposal will be made by November 1st. CMS is currently seeking public comment. If any of the above resonates with you and the inherent value of addressing goals of care within ACP and family care conference discussions, then I urge you not to sit silently on the sidelines while the “vocal minority” attempts to derail these efforts again. Talk about it, write about, and above all, help your patients to better understand it. If you are even more inclined, send in a comment to let Medicare know you support their proposal and why: http://www.regulations.gov/#!documentDetail;D=CMS-2015-0081-0002


Epstein_Howard_HeadshotHoward Epstein, MD, FHM is Chief Medical Officer at PreferredOne Health Plans in Minnesota. He is a hospitalist board certified in hospice and palliative medicine. He is the founding medical director of the Palliative Care Team at Regions Hospital in St. Paul, MN, former president of Minnesota Network of Hospice and Palliative Care, serves on the Honoring Choices Minnesota Advisory Council, and is a member of the Society of Hospital Medicine Board of Directors.

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