Sunday, October 11, 2009

PBS NOW Gundersen Lutheran Hospital & Advanced Care Planning

With a tagline like: "What exactly is a death panel?" PBS is starting to sound like an afternoon tabloid show, but they end up covering the topic very well in the 25 minute clip now available online.  I am sure many palliative care people are familiar with the Gundersen Lutheran "Respecting Choices" project to increase the communication and recognition of advanced care planning through living wills, health care power of attorney's, POLST's and consultation with medical staff.  If you are not familiar with it here is a brief background:

The program started in the early 90's with an oncologist, nurse practioner, and a clinical ethicist, who is also featured in the video clip (Bud Hammes, Ph.D.).  And within two years they had a 85% penetration of advanced directives and a shocking 95% were found in the chart.  I say shocking because if you have ever spent more than a week on a palliative care team you realize you may be the first one to ask more than one question about advanced directives and your team is the one who actually gets the information in the chart.  There are similar projects based off of "Respecting Choices" sprouting up around the US and also internationally.

The clip also featured a palliative care doctor making home visits!  Awesome!

The only slight but important error in the clip mentioned by the reporter and Hammes was that Medicare does not reimburse for having these conversations.  That is actually not true.  Medicare does reimburse for these conversations indirectly via physicians billing for time spent with patient and family.  A longer conversation means a physician could bill using a prolonged service code.  Billing by complexity will always bring in more revenues compared to billing by time so it basically undermines good communication by nudging a medical system towards seeing more patients in shorter amounts of time and then billing for the higher complexity.  So the bill tried to set up a unique reimbursement structure which the details of relative compensation compared to complexity or time based billing were still unclear.  Regardless that section of the bill is not in the Senate version and is still (I think) in the House version and is now political poison given the hyperbole.

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