Wednesday, January 5, 2011
In again, out again: CMS Reimbursement for Advance Care Planning
In a disheartening and aggravating (to me, anyway) reversal, the Obama Administration has announced that the recent approval (for reimbursement purposes) of time spent counseling patients on advance directives will not go in to effect after all (see today’s New York Times article). As the administration spokesman pointed out, this change does not prevent patients and providers from having these important conversations, but it means that this continues to be a non-billable service under CMS (Medicare) regulations.
Just a month ago a “final” Medicare rule was announced that would provide reimbursement to physicians who offer counseling on advance care planning during a routine annual well-care visit. It was met with excitement and praise from CAPC and other organizations that advocate for patient-physician discussions about the patient’s wishes should they become incapacitated and unable to make health care decisions. As the NHPCO web site pointed out, these discussions are strictly voluntary. It also makes sense from the perspective of advocating individual rights and strengthening patient, family, and patient-physician communication and relationships.
I’m having trouble figuring out why the administration would reverse this decision. I have not heard anything from the “death panel” scaremongers that would give them the willies as they go into a new Congressional era in which House Republicans have pledged to repeal the health reforms enacted less than a year ago (have you heard the headlines that use the phrase “Republicans plan to repeal health care”?—that’s weird in itself). The rather lame excuse given is that a procedural lapse caused the new rule to be omitted in an earlier, proposed, set of rules, so this part of the rule did not have adequate time for public comment. The result, of course, is confusion at all levels and very mixed messages coming from the administration.
In the grand scheme of things, this was (and is) a relatively small bit of the overall health care conversation and policy decision-making. It is also highly symbolic (and, as we have seen, open to highjacking and distortion by those who are opposed to any government involvement in health care reform). Advance care planning and end-of-life care have been largely missing from thoughtful conversation about health reform in Congress. I suppose this might be a trigger to try to jump-start that conversation again, but, as I said in my opening sentence, it is disheartening.
(Note this post written by Thomas Quinn, but posted by Christian Sinclair)
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9 Responses to “In again, out again: CMS Reimbursement for Advance Care Planning”
January 05, 2011
I heard a Republican rep today on the radio say that his hope is that the house will vote to repeal Obamacare* (likely to happen). He then hopes that enough of the Democratic majority in the Senate will "counter-intuitively" (ie highly unlikely) vote to repeal to "protect" themselves in the 2012 election. This would then leave it up to Obama to decide on a veto of the repeal thus REALLY making it "Obamacare" if he vetoes the repeal. A dreamy scenario perhaps for this particular rep.
I don't know if the administration has ANY fear of that scenario playing out. If they do, then it's understandable (from a political standpoint) why they would take this lightning rod out again (even though the lightening rod is made out of plastic).
I share your sentiment that this provision is chump-change in the grand scheme of things. It's a pawn in a larger political game and has done nothing but draw negative attention to something that most people would say is important (even though it's difficult for most to think about).
as far as billing for this service goes, physicians CAN bill for ACP discussions. Option 1: bill for time spent counseling or Option 2: If changes in code status are decided upon during ACP, my understanding is that this is considered to contribute to high-complexity management, so can potentially bump up your E/M coding. However, the billing is still not proportionate to the time, effort, and skill that these conversations take.
* I also heard that the Obama admin bought google ads so that when you search for "Obamacare," it's the first link at the top of the page. maybe we should all start using the term!
January 06, 2011
See a recent opinion piece by Charles Krauthammer in The Washington Post:
Government by regulation. Shhh.
January 06, 2011
Correct me please if I am wrong, but the regulation pertains to counseling on advance care planning DURING a routine annual well-care visit. This change-but-no-change happens to have little to do with our practice, which remains reimbursable; the regrettable consequence is that we will likely perform simple tasks that could, and should be completed by the primary providers.
January 06, 2011
I just thought to myself 'So it's going to be like this...well happy f**king 2011.'
The rule change is of such minor importance - so unlikely to change anything or 'transform' advance care planning or anything like that. Nonetheless, a nice symbolic nod by a payor that ACP is valued.
That is however apparently too much for our political system however.
We have on one side a group of highly organized and profoundly, profoundly cynical and craven individuals who are gleefully twisting something that is about empowering patients to get the medical care they actually want into death panels/what have you. There is nothing more to this than politics and if there's something that's about protecting patients that can be turned into a big government conspiracy then, well, patients be damned. Cynical, and craven.
And on the other side we have an administration which is either just inept and bungling and making mistakes which make it look weak and cowering; or it just really is weak and cowering. What happend to the president who spoke candidly, and thoughtfully, about his grandmother's terminal hip replacement?
It's going to be a good year.
January 09, 2011
As a colleague on the Community Ethics Committee pointed out, the health care law got in trouble for allowing the doctor to charge for his or her time in discussing voluntary advance care planning with the patient. These conversations are crucial to helping a patient understand options and set goals of care. Now, those discussions may continue, but they won’t be "billable" in a pure sense. As such, they are not systemically encouraged, and these doctor-patient dialogues need to be systemically encouraged, for ethical reasons, for economic reasons, and simply to encourage good care.
(see www.medicalethicsandme.blogspot.com)
January 10, 2011
The thing that frustrates me about this issue is the lack of a broad based coalition of support. How come there are not nephrologists, cardioligists, neurologists, geriatricians and critical care docs clamoring for this?
Honestly I cannot blame Joe Public for being somewhat suspicious if it was only hospice and palliative care orgs and providers jumping up and down for advance care planning. It feeds right into the 'death panel' meme. I have had families ask me if they were transferred to hospice because of 'Obamacare.' More than once. And then after reviewing the medical history, the consensus from all the medical providers and echoing the patients wishes to not be as aggressive. After all that discussion, I feel there is some suspicion of the 'system.' I think for a small percentage of people that will always hold true.
I think we as a field need to look beyond our passionate base if we are ever to get the attention and respect of the public for the issues we care about.
January 11, 2011
I subscribe to a physician-only website which hosts various topics, and this is one that comes up frequently. This particular website tends to lean very conservative, and the comments regarding this issue tend to pillory the concept of reimbursing docs for ACP. They harp on about government control of the medical profession, how Obama is trying to use doctors to limit treatment and therefore save money. They tend to suggest that this is a dangerous thing and docs who accept this money have no ethics. I was shocked to hear other docs complain about this, alhough I think this reflects the overall frustration many feel at the PPACA.
March 27, 2011
As a colleague on the Community Ethics Committee pointed out, the health care law got in trouble for allowing the doctor to charge for his or her time in discussing voluntary advance care planning with the patient. These conversations are crucial to helping a patient understand options and set goals of care. Now, those discussions may continue, but they won’t be "billable" in a pure sense. As such, they are not systemically encouraged, and these doctor-patient dialogues need to be systemically encouraged, for ethical reasons, for economic reasons, and simply to encourage good care.
(see www.medicalethicsandme.blogspot.com)
March 27, 2011
I just thought to myself 'So it's going to be like this...well happy f**king 2011.'
The rule change is of such minor importance - so unlikely to change anything or 'transform' advance care planning or anything like that. Nonetheless, a nice symbolic nod by a payor that ACP is valued.
That is however apparently too much for our political system however.
We have on one side a group of highly organized and profoundly, profoundly cynical and craven individuals who are gleefully twisting something that is about empowering patients to get the medical care they actually want into death panels/what have you. There is nothing more to this than politics and if there's something that's about protecting patients that can be turned into a big government conspiracy then, well, patients be damned. Cynical, and craven.
And on the other side we have an administration which is either just inept and bungling and making mistakes which make it look weak and cowering; or it just really is weak and cowering. What happend to the president who spoke candidly, and thoughtfully, about his grandmother's terminal hip replacement?
It's going to be a good year.
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