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Government Payments for End-of-Life Counseling Draw More Support Than Criticism

Medicare officials received more support than criticism for a plan to pay health care providers for time spent counseling people about their medical options in case of terminal illness or failing health, an approach that was derided in the past as a path toward so-called death panels.

About 500 comments submitted on a 2016 Medicare rule for paying physicians supported end-of-life counseling, with most calling on the Centers for Medicare and Medicaid Services to finalize a plan to create a new payment category, CQ Roll Call found in a review of comments posted publicly as of last week. About 100 comments raised objections.

Medicare officials will make their final decision as part of the broader rule on payments to physicians, which will be unveiled this month.

Powerful lobbying groups, including AARP, the American Bar Association and the American Heart Association, were among those pressing for the creation of the payment. The American Medical Association said the CMS plans to pay doctors and other qualified health professionals about $86 for the first half hour spent on such counseling, with about $74 for each subsequent half hour.

The AFL-CIO was among the groups calling on the CMS to establish a national policy on advance care planning, instead of allowing local administrative contractors to decide.

The labor giant argued that people on Medicare shouldn’t be charged directly for counseling, on the grounds that cost-sharing might discourage the widespread use of advance care planning. The services are meant to help people and their families consider ahead of time an approach to medical interventions, especially in cases where treatments may have little potential to restore or maintain a patient’s health in the face of advancing illness.

“Through documentation of those preferences, beneficiaries can help ensure their instructions are followed and preferences honored if they become unable to make their own health care decisions,” wrote Karin S. Feldman, AFL-CIO benefits and social insurance policy specialist.

Advance care planning is expected to allow more people to die at home, as they would prefer, rather than in intensive care units, wrote Josh Rising, director of health care programs for the Pew Charitable Trusts, in a comment.

“When advance care planning conversations have not occurred, family members and caregivers are forced to guess at what their loved ones would want and often experience stress, guilt, and regret when they are not confident that they know their loved one’s wishes,” Rising wrote.

Still, many people remained skeptical of the federal government playing a role in such discussions. The conservative Association of Americans Physicians and Surgeons said there would be “no limit to the drain on Medicare from repeated use” of the advance care planning payment codes. The counseling sessions would attempt “to induce a patient, or his family, to consent to the withholding of care and even food or water,” the association said. “Discussion becomes harassment at some point, and Medicare should not be paying caregivers to harass patients.”

The current CMS proposal raised little uproar, compared with the reaction to a similar provision in a bill in 2009. Objections from Republicans, including former vice presidential candidate Sarah Palin, caused a provision on advance care planning to be dropped from the 2010 health law (PL 111-148, PL 111-152).

Rep. Steve King, R-Iowa, has drawn only three Republicans co-sponsors for a bill (HR 3251) to block the creation of a Medicare payment for advance care planning. In contrast, Rep. Earl Blumenauer, D-Ore., drew eight GOP sponsors and 51 Democratic supporters for a bill in the 113th Congress that would have established such a payment. Rep. Phil Roe, R-Tenn., joined Blumenauer in a July letter to the CMS supporting the advance care planning payment.

In the 114th session, Sens. Mark Warner, D-Va., and Johnny Isakson, R-Ga., have two Republican and two Democratic co-sponsors for their bill (S 1549) to create a Medicare payment for advance care planning.

Former Senate Majority Leader Bill Frist, R-Tenn., has endorsed the idea, recalling in an op-ed column earlier this year his own experiences as a surgeon, saying he had seen “countless instances where patients near the end of life undergo aggressive medical interventions in order to prolong the inevitable.”

Some private insurers already pay for such counseling, following a 2014 decision by the AMA to create a kind of billing code for the services. Blue Cross Blue Shield of Massachusetts, which covers counseling, urged the CMS to support training for doctors in holding these conversations.

“CMS’s proposal highlights the importance of these conversations between patients and their practitioners,” Deirdre Savage of Blue Cross Blue Shield wrote in the comment. “In addition, separate payment offers greater flexibility so that patients can engage in these important conversations whenever is most natural, including before their illness or condition progresses.”

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