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    Why end-of-life care planning is a necessary service

    Do most physicians know what treatments their patients would want if they became seriously or even terminally ill?

    Since 2016, physicians have been able to bill Medicare’s Physician Fee Schedule for a visit with a beneficiary to discuss advance care planning and preferences about the patient’s medical care for some future point when the patient’s condition worsens or the person is no longer able to express care preferences. 

    This care planning conversation might make some patients—and physicians—uncomfortable, but it is voluntary and it offers an opportunity to explore the patient’s values and wishes in a circumstance when no crisis is looming.

    “We are quickly moving to a healthcare payment system based on value and outcome,” says Jean Acevedo, a healthcare billing and compliance consultant in Delray Beach, Florida. “Any service that can help patients make personal decisions about their healthcare, based on how much aggressive treatment they are likely to want or not want in those situations, is a good thing.”

    Not only that, she says, but Medicare encourages physicians to do an annual wellness visit with their Medicare patients—even sending emails to beneficiaries reminding them of this service. If at that wellness encounter a discussion about advance care planning is initiated, there is no co-pay for the patient, but the physician is able to charge an additional fee for the advance care planning part of the visit.

    Advance directives are written legal documents designed to allow patients to guide their medical care at a future time when they can no longer speak for themselves. One type of advance directive, the living will, describes medical treatments a person might want or not want, while the Durable Power of Attorney for Health Care Decisions names a surrogate authorized to speak on the patient’s behalf. 

    In a number of states, a related document called POLST (Physician Orders for Life-Sustaining Treatment) allows patients and their physicians to spell out more specific treatment choices when the patient’s advancing illness makes them timelier.

    In all of these cases, the advance directive document should follow a thoughtful conversation. 

    The patient’s attending or primary care physician often is best situated to guide such conversations, based on a history with the patient and an understanding of the kinds of medical issues that are likely to shape the patient’s future medical needs.

    Those future needs are far from self-evident, but the physician can help the patient understand what is reasonable to expect. While advance directive documents are often associated with a preference to withhold aggressive treatments such as resuscitation, mechanical ventilation or feeding tubes, they can also be used to capture preferences for everything medically appropriate to be done in a crisis.

    The legal framework for advance directives varies considerably from state to state, but a number of national groups, including Five Wishes, the Conversation Project, and many health plans, try to make it easier for patients to access sample documents and tools for completing them. Other groups are developing electronic registries to make the patient’s advance directive more easily accessible in a crisis.

    Larry Beresford
    Larry Beresford is a contributing author for Medical Economics.

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