The Essence of Time

March 28, 2016

Author: Sarah Willson
Vice President of Clinical and Regulatory Affairs

April 15 is infamous for being “tax day.” Walking down the street, I believe you would be hard pressed to find someone who didn’t recognize the day. However, when you ask people about April 16, it’s unlikely that they know it’s National Health Care Decisions Day. NHDD inspires, educates and empowers people about the importance of ACP. NHDD also encourages patients to express their wishes regarding health care, and for providers and facilities to respect those wishes, whatever they may be. The theme for 2016 is "It Always Seems Too Early, Until It’s Too Late."

In October 2015, the Centers for Medicare & Medicaid Services released proposed policy, payment and quality provision changes to the Medicare physician fee schedule for calendar year 2016. One of the provisions that has gone into effect surrounds advanced care planning. The rule finalizes a proposal that will better enable seniors and other Medicare beneficiaries to make important decisions that give them control over the type of care they receive and when they receive it.

Consistent with recommendations from the American Medical Association and a wide array of stakeholders, CMS is establishing a separate payment and payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners. The Medicare statute currently provides coverage for ACP under the “Welcome to Medicare” visit, which is available to all Medicare beneficiaries. However, they may not need these services when they first enroll. Establishing separate payment for ACP provides practitioners’ additional time to conduct conversations, as well as provides beneficiaries and practitioners a greater opportunity and flexibility to use planning sessions at appropriate times. CMS is finalizing payment for ACP when it is included as an optional element of an annual wellness visit.

For Medicare beneficiaries who choose to pursue it, ACP is a service that includes early conversations between patients and their practitioners, both before an illness progresses and during the course of treatment, to decide on the type of care that is right.

As a society there seems to be a lot of us on either side of the pendulum. Some feel like they have failed as providers if they discuss a person’s wishes for health care as their disease progresses beyond the capabilities of technologies “cure.” Others advocate for treatments to end one’s life, which is a thought filled with moral, legal, ethical, religious and personal conflict. In the middle, however, are people who desperately want to feel better. To be guided along the continuum of quality of life as defined by them.  However, they are not medically trained, they don’t understand all of the consequences of their decisions, and they too may believe there is nothing beyond cure but death. When this dilemma presents itself to our emergency departments it is emotional, sporadic, ill-informed and costly. I’m not only speaking of the cost of potentially unwanted treatments, but primarily that of time. The time they would have spent and how they would have spent it knowing that their disease has progressed beyond cure and there is always hope for dignity, comfort and quality of life. There is always something that can be done until our last breath. The crux here is that someone has to first have had the conversation. This is a conversation with their health care provider, their family and ultimately expressed in the form of a health care surrogate or living will.

A recent article in USA Today by Phil Galewitz, with Kaiser Health News, discusses the physician role in advanced care communication with seniors and payment for such discussions. It’s an interesting article, one that we should take a moment and evaluate for the sake of what we are in health care and what health care ultimately represents. I especially was touched by the following excerpt as a 91-year-old woman tells her physician that she doesn’t want to spend the rest of her days seeing doctors.

“You don’t have to, but you have to tell me what you do want,” Dr. Newfield replied.

“I’m not afraid of dying. I’m afraid of being 106.”