On Friday, October 31, 2015, the chief medical officer of
the Centers for Medicare and Medicaid Services announced a final rule which
details how Medicare will pay practitioners to have conversations with patients
about how they would like to be cared for at the end of life.
Under the regulation, the patient is not obliged to have these conversations
after a terminal diagnosis is made, or shortly before death is anticipated; the
conversations may take place at any time, even before the patient becomes ill.
The conversation may include discussions about life-sustaining treatments
before they may be necessary, and about advance directives and the
identification and appointment of a legally authorized representative to participate
in the shared decision making progress if the patient were to lose decision
making capacity. The rule, which will take effect in January 2016, creates new
codes for reimbursement under the Medicare physician fee schedule.
It may seem remarkable that there should be any question
about reimbursement for these often-time-sensitive, patient-directed
conversations or discussions at all. But because Medicare payments have
traditionally been tied to physicians completing and documenting finite “tasks”
or “procedures,” these conversations have been “bundled” with other inclusive
duties or responsibilities (such as taking a history or performing a physical
or developing a treatment plan). The idea that Medicare should pay specifically
for the service comes from the belief that if physicians received fairer
compensation for providing the conversation and discussion, they would be
better incentivized to comply. (Of course, this may or may not be the case, since many physicians clearly have
been doing this all along as evidenced by the increased referrals to palliative
care and hospice providers and services over the years.) But from 2013 Medicare
data about terminally ill cancer patients, only about 47% of these patients
receive hospice care, and the average length of stay in hospice is about 17
The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.