Have you been in the position of assisting a family member or friend make medical decisions when nearing the end of life? If so, did you feel that you had a complete understanding of the options that were available, and the potential outcomes related to those options?

I have written several articles to encourage people to think about end-of-life issues before they occur. On a national level, this topic grabbed the spotlight when the Affordable Care Act was being debated in Congress a number of years ago. Specifically, there was legislation in the Act through which physicians could bill Medicare for end-of-life or advanced care planning discussions with patients. This legislation was viewed by some as a method to restrict care, and the term “death panels” arose. The protest was loud enough to result in the legislation’s removal from the Act.

Currently, end-of-life discussions are covered by Medicare only if they take place within the context of an initial visit after first enrolling in Medicare. The Centers for Medicare and Medicaid Services is now considering expanding this coverage. The process started last year, when the government assigned two code numbers for end of life discussions between physicians and patients, but did not make them payable.   In July of this year, a 282 page document was released outlining proposed changes to Medicare payment policies for physicians’ fees and other services under Medicare Part B for 2016. A wide variety of services are discussed in the document, and one proposal is to activate these two codes; #99497 for a 30 minute discussion of end-of-life planning with a patient or designated representative, and # 99498 for an additional 30 minutes of discussion. The proposal does not set a reimbursement rate, however.

A decision about the proposal may be made as early as November. Some people may argue that the government just wants to reduce costs by trying to limit the number and types of tests and procedures that will be performed near the end of life. While the cost of care may be reduced, more importantly, the activation of these codes will allow physicians greater opportunities to help patients understand that they have choices during this very personal time. The availability of a thorough explanation of treatment choices and expected outcomes will allow each patient to determine the path that is most appropriate for his/her own situation and goals.   Shouldn’t every individual have the right to direct his/her own care? It is difficult to direct that care if discussions haven’t taken place which allowed the individual to gather information, ask questions, and work through their feelings about the sensitive issues which can occur at the end of life. Discussions held prior to the time of need can also help care providers and family members feel more secure in pursuing or withholding treatment for an individual who becomes incapacitated.

So far, public response to this proposal has not been as vocal as it was during the Affordable Care Act debate. The government was accepting comments about all of the proposed changes for Medicare payment policies which were contained in the document. The comment period has now closed, but submitted comments can be viewed at www.regulations.gov. Search for “CPT code 99497”. Many of the comments are related to other services; however a quick glance at the first 75 comments (out of over 2,000) revealed that almost 20 of them were specifically related to the proposal to reimburse physicians for advanced care planning discussions. 72% of these respondents supported this proposal.

As a professional who has spent many years working with seniors and their families, I have seen many people struggle with the complicated and emotional decisions that can arise at the end of life. Advances in medicine have provided many extremely ill people with a second chance at life; however these advances have also created many gray areas in the dying process. Hopefully, the final decision about this proposal will encourage advanced care planning discussions to occur, not just between physicians and patients, but also between individuals and their loved ones.

Karen Kaslow, RN, BSN

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