Two Years After “The Talk”: What Now?

Since January 1, 2016, Medicare has reimbursed physicians for time spent engaged in conversations with their patients about advance care planning and their end-of-life wishes. 

How successful has the effort been?  In many ways, it depends on who you ask. 

According to a study published by Kaiser Health News, nearly 575,000 Medicare beneficiaries took part in advance care planning conversations with their physicians during the first year the benefit was put into effect. That’s almost double the number (300,000) the American Medical Association had predicted.

An Under-Utilized Benefit 

Even so, it represents only about one percent of the more than 56 million Medicare beneficiaries enrolled at the end of 2016.

Few healthcare professionals question the importance of having such conversations. After all, end-of-life care planning tends to be a topic that most people avoid. A study published by Health Affairs in July of 2017 found that only one in three U.S. adults actually completes any type of advance directive for end-of-life care – such as a living will, healthcare power of attorney, or Provider Orders for Life-Sustaining Treatment (POLST) document.

By introducing two new billing codes in support of physician-directed advanced planning conversations, the Centers for Medicare and Medicaid Services (CMS) signaled a desire to alleviate that under-utilized yet crucial part of the hospice patient’s care plan.

Changing the Conversation Focus

Another key concern, particularly for palliative care specialists, is how such end-of-life conversations are structured.

“It’s a conflicting platform,” explains Dr. Tim Ihrig, Chief Medical Officer for Crossroads Hospice & Palliative Care. “In medical education, we’re taught to address pathology and disease. But there’s an inevitable turning point with every human being, every physical organism. Eventually we are going to die. And there is a turning point where functional capacity declines just because the body wears down.”

Most clinicians are taught that when there is an increase in a pathology, then it’s necessary to ramp up efforts to overcome that pathology Dr. Ihrig says. It’s no wonder, then, that statistics show that 80 percent of healthcare spending is taken by only 15 percent of the population – to the point where healthcare now accounts for 20 percent of the nation’s gross domestic product.

“We are taught to escalate what we do to that disease, to that person,” says Dr. Ihrig. “But if we’ve hit this inflection point, no matter what I do, it’s going to potentiate a decline. You can’t beat Mother Nature.”

Patient-Directed Priorities 

According to Dr. Ihrig, effective end-of-life conversations should be empowering for the patient seeking consultation. 

“If a primary care physician simply says: ‘Do you want me to do everything possible?’  90 percent of patients will say ‘Yes.’  There’s no context,” he says.

A more empowering approach would be to discuss with the patient what is most important to them – from a physical, medical, emotional, and spiritual standpoint.

“The conversation is not about dying. It’s really about living with disease based on true, informed consent. It’s about full transparency,” says Dr. Ihrig.

And as part of that discussion, it’s important to talk about what’s sacred to the patient as an individual, he says.

“We need to understand that in order to align what’s sacred with realistic goals,” Dr. Ihrig says. “Any decision the patient then makes is empowering and inspiring. It’s not giving up. Even if the patient decides not to pursue an aggressive clinical treatment, it’s still a decision to own their journey. To me, that’s the antithesis of giving up. And if a cure is not possible, it doesn’t mean we don’t fight.”

The Palliative Option 

That’s also why palliative care options should be fully discussed with patients as part of the Medicare-sponsored advance planning conversations.

“It’s not just: ‘If your heart stops, do you want CPR?’” says Dr. Ihrig. “It’s really the essence of living with a severe, chronic, potentially fatal disease. Whatever you decide as a patient, I’ll walk beside you one day at a time. The question is ‘what’s most important to you?’”

Right now, too few primary care physicians have the skill set, or familiarity with the vernacular, to guide such conversations, Dr. Ihrig explains. So in application, while the advance planning conversation is a step in the right direction, there needs to be greater understanding and education on the part of medical professionals about how to engage their patients in the kind of open and transparent discussion that will empower them to make decisions that address their personal needs and wishes.

We’ve come a long way since the Affordable Care Act was first introduced. Even so, there may still be quite some ways to go before advance planning conversations become widely effective tools for helping patients achieve fulfilling end-of-life care.

To learn more about hospice and advance care planning, visit our website or give us a call at 1-888-564-3405.

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