Reimbursement Key to Improving End-of-Life Care

Alicia Ault

March 20, 2015

Giving physicians incentives — and compensating them appropriately — will be key to helping the nation improve end-of-life planning and care, said experts gathered at an Institute of Medicine (IOM) forum today.

The National Action Conference on Policies and Payment Systems to Improve End-of-Life Care was held to discuss how to implement the recommendations in IOM's September report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.

Senate Aging Committee Chairman Susan Collins (R-Maine) said at the meeting that there are philosophical and practical issues that keep Americans and their physicians from planning for end-of-life care or talking about it when it's most necessary. But there are also political obstacles, she said.

The Centers for Medicare and Medicaid Services (CMS) can take the lead, but has been slow to move, Sen. Collins said. Last year, she and Sen. Bill Nelson (R-Fla.) urged CMS to finish its work on developing codes to reimburse physicians for end-of-life discussions.

The agency proposed two new codes in the 2015 Medicare physician fee schedule, but has not finalized those codes for payment.

"Until we solve the reimbursement issues, I don't think we're going to make true progress," Sen. Collins said.

Sen. Mark Warner (D-Va.), a member of the Senate Finance Committee, who has taken a personal interest in end-of-life issues, told the IOM attendees that he will introduce his Care Planning Act again in this session of Congress. That bill, cosponsored by Sen. Johnny Isakson (R-Ga.), was originally offered in 2013, but did not advance.

Among other things, the bill would create a new benefit under Medicare and Medicaid that would cover team-based discussion of goals of care and values and a documented plan that reflects the patient's goals, values, and preferences.

"For a lot of doctors, this is an uncomfortable conversation," said Sen. Warner. He said he believes legislation is going to be the only way to change the culture and create a system that appropriately compensates healthcare providers.

Patrick Conway, MD, CMS deputy administrator for innovation and quality and chief medical officer, told the meeting that the end-of-life codes would be part of the 2016 fee schedule, but that he could not talk further about reimbursement.

He also said that the agency's Center for Medicare and Medicaid Innovation will soon announce winners of grants for the Medicare Care Choices Model. The center received an avalanche of applications, which has kept the agency from announcing grantees sooner, Dr Conway said.

Under Care Choices, Medicare beneficiaries will be able to receive palliative care while concurrently receiving curative care. "We are very excited about that model," Dr Conway said.

The agency will study whether the Medicare Care Choices Model improves quality of care and patient and family satisfaction and has any impact on the use of curative services or hospice.

Philip A. Pizzo, MD, cochair of the IOM Committee on Approaching Death, cautioned that "the issue of cost should not dominate our discussion." When writing the Dying in America report, "We were very clear that we were going to focus on quality — quality of life and quality of death," said Dr Pizzo, who is David and Susan Heckerman Professor of Pediatrics and of Microbiology and Immunology, Stanford University, California.

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