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Editorial: Medicare reimbursement for end-of-life planning long overdue

Sat., July 11, 2015

It’s perhaps fitting that in the same week Sarah Palin shut down her subscriber-based online channel, Medicare announced it will reimburse health care providers for talking with patients about what care they want after they become too ill to speak for themselves.

The wise and too-long-delayed decision to pay doctors for engaging patients in discussions about end-of-life care was a feature of the proposed Affordable Care Act before the former vice presidential candidate took to Facebook and denounced the policy as the formation of “death panels.” The fact-checking website of the St. Petersburg Times, Politifact.com, dubbed the death-panel claim its “Lie of the Year for 2009,” but the damage was done. Congress removed the proposal from the bill.

It’s a sad reflection on our politics that it’s taken six years to revive a policy that is wholeheartedly supported by the medical community and end-of-life experts. Palin was back on Facebook this week re-sounding her alarm, but it’s clear from her rambling post that she still doesn’t understand the issue.

End-of-life directives are controlled by the patient. Doctors, nurse practitioners and physician’s assistants go over the options with patients when they are of sound mind. Patients can then have substantive discussions with loved ones before deciding on a plan. Sensitive questions such as whether patients want to die at a hospital, at home or in hospice care are broached.

Now, patients often become incapacitated before those issues are resolved, and family members are placed in the awful position of guessing. Without a plan, patients may suffer through unwanted treatment by physicians who don’t know them. Medicare pays for all of that, but before the policy change, it would not pay doctors who cared enough to talk to their patients about their options.

Two myths need to be put to rest about the policy.

First, the notion that this is how health care will become rationed is nonsense. The decision belongs to patients. If they want doctors to take aggressive action, they will do so, and Medicare will reimburse. The major medical associations support end-of-life directives, even though doctors and hospitals stand to lose money.

Second, the idea that these discussions are already widespread is false. Most people don’t have a plan, and most health care providers don’t bring up the subject. The Institutes of Medicine issued a report last year that said reimbursing doctors was one of the keys to changing the culture on this delicate subject.

Many patients who are counseled make choices that fall short of a hospital’s default position of aggressive acute treatment. But they get what they want, and physicians avoid invasive efforts they know are unlikely to succeed. The bonus is that it stretches Medicare’s budget.

Medicare is making a rational, compassionate, patient-centered decision, and it’s long overdue.