Reimbursing doctors for discussing goals of care with their patients- finally, a good health care reform idea!

Part of the proposed health care reform bill that I like is the idea to reimburse physicians for having an "advance care planning" discussion with their patients once every 5 years. This is something I do with my patients often, and I have wished many times that Medicare would recognize the value of this skill, and the time it takes to perform it, by offering specific reimbursement for the discussion. Unfortunately, some Republicans are saying that supporting a patient-physician conversation about goals of care and end-of-life options will "start us down a treacherous path toward government-encouraged euthanasia". I disagree.

Section 1233 of HR 3200, the proposed health care bill, is titled "Advance Care Planning Consultation". It allows a physician to be reimbursed for leading his or her patient in a discussion about the patient's wishes in certain medical situations. I find these discussions to be very helpful for patients and doctors. Patients have the chance to think through different scenarios and ask questions about what to expect. They also have the opportunity to put these wishes in writing, and to select a surrogate decision maker for a situation in which they are unable to express their own wishes. Doctors can gain insight into their patient's preferences so that, when they become ill, the doctor knows better how to care for them. Family members are often involved in these discussions, and the process helps prepare the entire family for unexpected events so they don't have to panic in a crisis. These discussions often occur around the time of a new diagnosis, a serious change in condition, or a change in living situation such as a move to a nursing home.

The bill does not mandate these discussions, as some commentators and even congressmen have suggested. It simply rewards clinicians for taking time to assist their patients with advance care planning, if they chose to do so. The bill also does not mandate the specifics of the conversation. It mentions many of the standard treatments that are discussed in an advance care planning session, such as intravenous antibiotics, artificial feeding and hydration, and hospitalization. The bill does not mandate what is said or decided about these issues; it simply allows that they can be part of a conversation that would qualify as advance care planning.

My only concern about a bill like this is that it recommends: "An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title". I am a staunch supporter of palliative care and hospice, when appropriate, but in states where physician-assisted suicide (PAS) is legal, the phrase "continuum" could be used to mandate that physicians offer this option to their patient in any advance care planning discussion. However, the bill states that this discussion can include such an explanation, not must, so the bill as it is currently written would not mandate offering PAS even where it is legal.

Though I have many problems with HR 3200, and I hope it does not pass in its current form, I am encouraged that reformers are recognizing the value of advance care planning, and that they are considering reimbursing physicians for taking time to providing this valuable service to their patients.

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