End-of-life counseling sessions, once decried by some conservative聽Republicans聽as 鈥渄eath panels,鈥� gained steam among Medicare patients in 2016, the first year聽doctors could charge the federal program for the service.
Nearly 14,000 providers billed almost $35 million 鈥斅爄ncluding nearly $16 million paid by Medicare 鈥斅爁or advance care planning conversations for about 223,000 patients from January through June, according to data released this week by the Centers for Medicare &聽Medicaid Services. Full-year figures won鈥檛 be available until July, but use appears to be higher than anticipated.
Controversy is threatening to reemerge in Congress over the funding, which pays doctors to counsel some 57 million Medicare patients on end-of-life treatment preferences. Rep. Steve King (R-Iowa) introduced a bill last month, the聽, which would revoke Medicare reimbursement for the sessions, which he called a 鈥測et another life-devaluing policy.鈥�
鈥淎llowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years,鈥� King said on Jan. 11.
While the fate of King鈥檚 bill is highly uncertain 鈥斅爐he recently proposed measure hasn鈥檛 seen congressional action 鈥斅爄t underscores deep feelings among conservatives who have long opposed such counseling and may seek to remove it from Medicare should Republicans attempt to make other changes to the entitlement program.
Proponents of advance care planning, however, cheered evidence of the program鈥檚 early use as a sign of growing interest in late-stage life planning.
鈥淚t鈥檚 great to hear that almost a quarter-million people had an advance care planning conversation in the first six months of 2016,鈥� said Paul Malley, president of Aging With Dignity, a Florida nonprofit. 鈥淚 do think the billing makes a difference. I think it puts it on the radar of more physicians.鈥�
Use of the counseling sessions is on track to outpace an estimate by the American Medical Association, which projected that about 300,000 patients would receive the service in the first year, according to the group,聽.
Providers in California, New York and Florida led use of聽聽that pays about $86 a session for the first 30-minute office-based visit and about $75 per visit for any additional sessions.
The rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions.
The new reimbursement led Dr. Peter Sutherland, a family medicine physician in Morristown, Tenn., to schedule more end-of-life conversations with patients last year.
鈥淭hey were very few and far between before,鈥� he said. 鈥淭hey were usually hospice-specific.鈥�
Now, he said, he has time to have thorough discussions with patients, including a 60-year-old woman whose recent complaints of back and shoulder pain turned out to be cancer that had metastasized to her lungs. In early January, he talked with an 84-year-old woman with Stage IV breast cancer.
鈥淪he didn鈥檛 understand what a living will was,鈥� Sutherland said. 鈥淲e went through all that. I had her daughter with her and we went through it all.鈥�
The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians鈥� assistants may also seek payment for end-of-life talks.
The idea of letting Medicare reimburse such conversations was first introduced in 2009 during debate on the Affordable Care Act. The issue quickly fueled allegations by some conservative politicians, such as former Republican vice presidential聽聽and presidential candidate John McCain,聽that they would lead to 鈥渄eath panels鈥� that could disrupt care for elderly and disabled patients.
The idea was dropped 鈥渁s a direct result of public outcry,鈥� King said in a statement.
鈥淭he worldview behind the policy has not changed since then, and government control over this intimate choice is still intolerable to those who respect the dignity of human life,鈥� he said.
But in 2015, CMS officials quietly聽聽allowing Medicare reimbursement as a way to improve patients鈥� ability to make decisions about their care.
End-of-life conversations have occurred in the past but not as often as they should, Malley said. Many doctors aren鈥檛 trained to have such discussions and find them difficult to initiate.
鈥淔or a lot of health providers, we hear the concern that this is not why patients come to us,鈥� Malley said. 鈥淭hey come to us looking to be cured, for hope. And it鈥檚 sensitive to talk about what happens if we can鈥檛 cure you.鈥�
础听, a panel of medical experts, concluded that Americans need more help navigating end-of-life decisions. 础听聽found that 89 percent of people surveyed said health care providers should discuss such issues with patients, but only 17 percent had had those talks themselves.聽(KHN is an editorially independent program of the foundation.)
Use of the new rule was limited in the first six months of 2016. In California, which recorded the highest Medicare payments, about 1,300 providers provided nearly 29,000 services to about 24,000 patients at an overall cost of about $4.4 million 鈥斅爄ncluding about $1.9 million paid by Medicare.
The data likely reflect early adopters who were already having the talks and quickly integrated the new billing codes into their practices, said Dr. Ravi Parikh, an internal medicine resident at Brigham and Women鈥檚 Hospital in Boston, who has聽. Many others still aren鈥檛 aware, he said.
, a medical billing management service, found that only about 17 percent of 34,000 primary care providers at 2,000 practices billed for advance care planning in all of 2016.
The numbers will likely grow, said Malley, who noted that requests from doctors for advance care planning information tripled聽during聽the past year.
To counter objections, providers need to ensure that informed choice is at the heart of the newly reimbursed discussions.
鈥淚f advance care planning is only about saying no to care, then it should be revoked,鈥� Malley said. 鈥淚f it truly is about finding out patient preferences on their own turf, it鈥檚 a good thing.鈥�
KHN鈥檚 coverage of end-of-life and serious illness issues is supported by .