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Medicare considers funding end-of-life talks

DUNDEE, N.Y. — Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans.

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People are living longer with illnesses, and many want more input into how they will spend their final days, including whether they want to die at home or in the hospital, and whether they want full-fledged life-sustaining treatment, just pain relief, or something in between. Some states, including Colorado and Oregon, recently began covering the sessions for Medicaid patients.

But far more significant, Medicare may begin covering end-of-life discussions next year if it approves a recent request from the American Medical Association, the nation’s largest association of doctors and medical students. One of the AMA’s roles is to create billing codes for medical services, codes used by doctors, hospitals and insurers. It recently created codes for end-of-life conversations and submitted them to Medicare.

The Centers for Medicare and Medicaid Services would not discuss whether it will agree to cover end-of-life discussions; its decision is expected this fall. But the agency often adopts AMA recommendations, which are developed in meetings attended by its representatives. And the political environment is less toxic than it was when the “death panel” label was coined; although there are still opponents, there are more proponents.

If Medicare adopts the change, its decision would also set the standard for private insurers, encouraging many more doctors to engage in these conversations.

“We think it’s really important to incentivize this kind of care,” said Dr. Barbara Levy, chairwoman of the AMA committee that submits reimbursement recommendations to Medicare. “The idea is to make sure patients and their families understand the consequences, . . . so they can make the best decision for them.”

People want input into how they will spend their final days, including whether they want to die at home or in the hospital.

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Now, some doctors conduct such conversations for free or shoehorn them into other medical visits. Dr. Joseph Hinterberger, a family physician in Dundee, N.Y., wants to avoid situations in which he has had to decide for incapacitated patients who had no family or stated preferences.

Recently, he spent an unreimbursed hour with Mary Pat Pennell, a retired community college dean, walking through advance directive forms. Pennell, 80, who sold her farm and lives with a roommate and four cats, quickly said she would not want to be resuscitated if her heart or lungs stopped. But she took longer to weigh options if she was breathing but otherwise unresponsive.

“I’d like to be as comfortable as I can possibly be,” she said at first. “I don’t want to choke, and I don’t want to throw up.”

With reimbursement, “I’d do one of these a day,” said Hinterberger, whose 3,000 patients in the Finger Lakes region range from professors to Mennonite farmers.

If Medicare covers end-of-life counseling, that could profoundly affect the American way of dying, experts said. But the impact would depend on how much doctors are paid, the allowed frequency of conversations, whether psychologists or other nonphysicians could conduct them, and whether the conversations must be in person or could include phone calls with long-distance family members.

Paying for only one session and completion of advance directives would have limited value, experts said.

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