CMS Proposes Medicare Coverage for End-of-Life Care Discussions

On Wednesday, CMS released a proposed rule that would provide Medicare coverage for end-of-life counseling, the New York Times reports (Belluck, New York Times, 7/8).

The change was included in CMS' proposed updates to the 2016 Medicare Physician Fee Schedule (Robeznieks/Dickson, Modern Healthcare, 7/8).

Background

Reimbursement for end-of-life consultations have been included in bipartisan health reform bills in both the House and Senate, but no such bills made it to votes (Kenen, Politico, 7/6). However, lawmakers dropped efforts to include end-of-life planning in the Affordable Care Act later that year after opponents of health reform cast it as the start of "death panels" that would encourage euthanasia (New York Times, 7/8).

Earlier this year, the American Medical Association developed new billing codes for advanced-care planning in its 2015 physician payment rule (Armour/Radnofsky, Wall Street Journal, 7/8).

Increasing Need

As the U.S. population ages and awareness that certain interventions are ineffective at the end of life, physicians have supported private coverage of advanced-care conversations. Such conversations are already covered by some state Medicaid programs. In addition, some states have laws that facilitate placing end-of-life goals in medical records (Politico, 7/6).

Further, a report issued last year by an expert panel convened by the Institute of Medicine found the U.S. health care system is ill-equipped to handle end-of-life care. The report also found a gap between what services are available to those near the end of their lives and the care they actually want. The report recommended the U.S. overhaul its "broken" end-of-life care system to improve patients' quality of life in their final days and to cut rising health care costs (California Healthline, 9/18/14).

Proposal Details

Under the proposal, Medicare would reimburse providers -- such as nurse practitioners, physicians and physician assistants -- for in-person meetings with patients and their relatives or caregivers to discuss what patients would like to happen if they become too ill to voice their own decisions on their end-of-life medical care (New York Times, 7/8). The discussions would be voluntary for patients (Sedensky/Alonso-Zaldivar, AP/San Diego Union-Tribune, 7/8). CMS Chief Medical Officer Patrick Conway said the proposed rule "supports individuals and families who wish to have the opportunity to discuss advance care planning with their physician and care team." He added, "We think those discussions are an important part of patient- and family-centered care."

Further, Conway noted the proposal would not limit the number of such conversations Medicare would cover. He said, "The reality is these conversations, their length can vary based on patients' needs. Sometimes, they're short conversations -- the person has thought about it. Sometimes, they're a much longer conversation. Sometimes, they're a series of conversations" (New York Times, 7/8).

In addition, the proposal seeks comment on whether Medicare should cover advanced-care planning discussions as part of individuals' annual wellness exams.

The proposal will remain open for public comment until Sept. 8 (Wall Street Journal, 7/8). Conway said reimbursement rates for the counseling sessions and other details will be decided following the public comment period. According to Conway, a final decision will be made on the proposal by Nov. 1 (New York Times, 7/8). If adopted, the proposal would take effect on Jan. 1, 2016 (AP/San Diego Union-Tribune, 7/8). According to the Times, the proposal is expected to be finalized (New York Times, 7/8).

Potential Effects

According to the AP/San Diego Union-Tribune, the proposal would open up such coverage to 55 million Medicare beneficiaries. Medicare beneficiaries account for about 75% of U.S. residents who die each year, making the program the "largest insurer at end of life," according to the Kaiser Family Foundation (AP/San Diego Union-Tribune, 7/8).

Further, private insurers often look to Medicare to set coverage standards, which means more private health plans could offer such coverage. In turn, the proposal could cause more physicians to have such conversations with their patients (New York Times, 7/8).

Reaction

According to the Times, large medical organizations expressed support for the proposal. For example, Diane Meier, director of the Center to Advance Palliative Care, called the proposal "a huge step forward." She said, "I think it's great news that Medicare, the major payer for health care in the U.S., is now formally recognizing that advance care planning is worthy of its attention and reimbursement and that in fact it is a way to restore power and control to patients."

Still, Meier noted the need to ensure providers "know what they're doing and are well trained" in providing end-of-life counseling. She said the final rule should detail and require documentation of certain components of end-of-life care conversations for reimbursement (New York Times, 7/8).

Meanwhile, the American Medical Association also expressed support for the proposal. AMA President-elect Andrew Gurman said coverage for advanced care planning had "been mischaracterized in the past, and it is time to facilitate patient choices" on the issue (AP/San Diego Union-Tribune, 7/8).

The proposal also drew support from some lawmakers. Rep. Earl Blumenauer (D-Ore.) called the provision "long overdue," adding, "It has support in Congress and with over 60 organizations" (Wall Street Journal, 7/8).

However, the National Right to Life Committee said it opposes the proposal because it could cause patients to be pressured into forgoing treatment. Burke Balch, director of NRLC's Powell Center for Medical Ethics, said his group "feel[s] there is pervasive bias against treatment that is occurring in advance care planning that involves nudging individuals to reject lifesaving medical treatment," which is "motivated in large part by a desire to cut health care costs." Instead, Balch said NRLC is pushing for legislation that would direct Medicare to develop materials regarding end-of-life counseling reflecting various viewpoints, including those "concerned with protecting people's right to treatment" (New York Times, 7/8).