Should Medicare cover end-of-life discussions between patients and doctors?

Should the government pay for end-of-life consultations with doctors once  a year? Many on the right fear a slippery slope where such discussions could someday encourage patients to reject advanced care options which might prolong life. It's a legitimate question, as Breitbart points out:

Doctors and bureaucrats have insisted that end-of-life counseling would not lead to rationing, but "Burke Balch, director of the Powell Center for Medical Ethics at the National Right to Life Committee," disagreed, telling the Times that many doctors actually believe in "hastening death for those deemed to have a ‘poor quality of life.’" He said that doctors and bureaucrats may use these sessions to pressure patients to “to reject life-preserving treatment," according to the Times.

That was exactly the point Palin hammered during the "death panels" debate. She wrote that Obama's "Advance Care Planning Consultation" would have a "coercive effect" on patients because consultations would be "unauthorized whenever a Medicare recipient’s health changes significantly or when they enter a nursing home, and they are part of a bill whose stated purpose is 'to reduce the growth in health care spending.'" 

"Is it any wonder that senior citizens might view such consultations as attempts to convince them to help reduce health care costs by accepting minimal end-of-life care?" she wrote in 2009. She pointed out that even left-wing Washington Post "columnist Eugene Robinson, a self-described 'true believer,'" agreed that "If the government says it has to control health-care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending.”

The New York Times is reporting that the issue is making a comeback, largely because private insurers are covering such discussions.

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. People are living longer with illnesses, and many want more input into how they will spend their final days, including whether they want to die at home or in the hospital, and whether they want full-fledged life-sustaining treatment, just pain relief or something in between. Some states, including Colorado and Oregon, recently began covering the sessions for Medicaid patients.

But far more significant, Medicare may begin covering end-of-life discussions next year if it approves a recent request from the American Medical Association, the country’s largest association of physicians and medical students. One of the A.M.A.’s roles is to create billing codes for medical services, codes used by doctors, hospitals and insurers. It recently created codes for end-of-life conversations and submitted them to Medicare.

The Centers for Medicare and Medicaid Services, which runs Medicare, would not discuss whether it will agree to cover end-of-life discussions; its decision is expected this fall. But the agency often adopts A.M.A. recommendations, which are developed in meetings attended by its representatives. And the political environment is less toxic than it was when the “death panel” label was coined; although there are still opponents, there are more proponents, including Republican politicians.

If Medicare adopts the change, its decision will also set the standard for private insurers, encouraging many more doctors to engage in these conversations.

“We think it’s really important to incentivize this kind of care,” said Dr. Barbara Levy, chairwoman of the A.M.A. committee that submits reimbursement recommendations to Medicare. “The idea is to make sure patients and their families understand the consequences, the pros and cons and options so they can make the best decision for them.”

Now, some doctors conduct such conversations for free or shoehorn them into other medical visits. Dr. Joseph Hinterberger, a family physician here in Dundee, wants to avoid situations in which he has had to decide for incapacitated patients who had no family or stated preferences.

Private insurers have even more incentive to urge patients near the end of life to  forgo expensive, experimental treatments. So where does that leave those who wish to explore some of these complicated options for end-of-life care?

You're almost better off talking to a lawyer about some of these options than a doctor. A living will would cover most eventualities and since you're paying the lawyer to represent your interests, you can be reasonably sure he is advising you wisely.

But many, if not most Americans can't afford an attorney's counsel, which brings us back to square one. For example, hospice care can be extraordinarily complicated. Most hospices have several levels of care, and choosing the right one specific to your needs can be difficult. Resuscitation orders sound simple, but can also be fraught with complexity.

As our population ages, these questions will become more urgent and educating consumers more necessary. I fully understand the reasons why many would not want the government to intrude on these incredibly delicate issues - especially if there is an agenda at work. That's why what's needed are independent patient rights counselors whose only job is to represent the best interests of a patient. There is something similar in many European countries, although it's an open question how independent they are. Perhaps insurance companies can pay for them. Regardless, these are vital issues that most Americans are completely in the dark about and need to be educated in order to avoid problems when  our time on earth ends.

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