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Yesterday, legislation that would have reimbursed physicians for advance care planning discussions was stripped from Medicare regulations related to the Affordable Care Act (Health Care Reform Bill).

This was the second time such language was removed.  The first time, of course, occurred during debate over the bill in congress.  Sarah Palin said she did not want Obama’s “death panels” to decide who was worthy of care.  John Boehner (now house speaker) said the legislation was part of a slippery slope toward government sponsored euthanasia.  Not only was advance care planning legislation stripped from the bill, so were all measures related to palliative and end-of-life care.

What the administration couldn’t get through congress it turned to regulation to accomplish.  On Christmas 2010, the New York Times broke the story that the Obama administration and Don Berwick, director of the Centers for Medicare and Medicaid, incorporated language into Medicare regulations related to the health care bill that would reimburse physicians for voluntary advance care planning discussions during the newly covered annual visit.  We didn’t blog about this at GeriPal because representative Bleumenauer, author of the original legislation, cautioned against crowing about it, suggesting it should be a “quiet victory.”

Now, preparing to defend the health care bill against a new republican majority in the house intent on repealing the Affordable Care Act, Obama has reversed course.  They claim the language was removed for procedural reasons, but anyone can read between the lines.

A few thoughts about this.

Physicians should be reimbursed for time spent conducting advance care planning discussions with patients.  This will incentivize high quality care.  Lack of reimbursement for these long discussions is a major barrier to outpatient doctors engaging patients in the advance care planning process.

On the other hand, if I were to chose palliative care priorities for the Obama administration to focus on, this would not be tops on my list.  Other issues I would rank higher (thanks to Diane Meier for many of these):

  • Funding for palliative care graduate medical education (fellowship spots)
  • Funding for palliative care research
  • Incorporating palliative care into Accountable Care Organizations

And if I had a choice between legislation/regulation that includes advance care planning, but was likely to get hammered in congressional debate and sink as a result, and legislation/regulation without the language but with all of the other good things the Affordable Care Act accomplishes…I’d take health care reform.

This issue is important.  It’s just not worth the Obama administration falling on its sword.

by: Alex Smith

This Post Has 6 Comments

  1. After the death panel stuff, I didn't even feel disappointed when I learned this AM that this was repealed. I just sort of smiled ot myslef. I guess I'm just numb. I agree 100% that there are bigger priorities and the last thing we want to do is lose the whole health reform.

  2. I think this also shows the huge amount of education about Palliative Care that we still need.

    I know very intelligent people that just don't understand what the AD discussion thing was about…add that to distrust of the government and it's a recipe for paranoia.

    We need to keep trying to reach out to the public to help them understand advance care planning.

  3. I can't say I'm surprised. What did surprise me was the tone of the comments related to the NYT story today. A lot of the writers felt that "doctors shouldn't get paid extra for something they should be doing anyway." Hmmmm.
    In any case, our main focus now has to be on saving and advancing the aims of the Affordable Care Act. So many of the ACA's provisions benefit seniors–why aren't they up in arms about a potential repeal?

  4. Ironically, the AD discussion will most likely save money in the long run because of the cost of end of life care. It seems so obvious, but there seems to be so much misunderstanding related to this topic. All of your comments as physicians are to be admired.

  5. I believe that the right wing news media's 'death panel blitz' has nothing to do with their misunderstanding or true fear of advance care planning. Those opposed to health care reform see a vulnerable issue to get the public sentiment whipped up. All that outcry was Fox news' and right wing talk shows' willful misrepresentation of the issue in order to accomplish their goal-to take down all of health care reform. If the right was truly fearful of rationing do you think we might hear the same outcry about Arizona's (R) Governor's decision to stop Medicaid funding for transplants? The withdrawl of the advance directive language will make no difference to the attempts to repeal health care reform. Advance care planning is simply collateral damage.

  6. I think it would be fun to have a half day clinic where docs everywhere in the U.S. donated our time for the same four hours for the sole purpose of discussing advanced care planning with our patients. It would show legislators and the public how important we think advanced care planning is, how valuable our patients think it is and raise public awareness of what advanced care planning is and is not. On top of that, it would get a lot of patients thinking and planning with their doctors.

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