Death Panels Resurrected: Rep. Earl Blumenauer Wants End-Of-Life Conversations Reimbursed

Doctor and patient consult
If Earl Blumenauer has his way, Congress would approve a bill that provides Medicare reimbursements for physicians to consult with patients about advanced care planning and surrogate decision makers. National Cancer Institute

Even as House Republicans have vowed to repeal the Affordable Care Act commonly villified as "Obamacare," Representative Earl Blumenauer, D-Ore., works tirelessly to pass the original law's most incendiary component, which he authored himself: the death panel.

In reality, there never was a death panel or the slightest hint of one. In 2009, while debates over the health reform's laws were at full swing, conservative opposition famously distorted a provision that would have Medicare reimburse physicians for having discussions about end-of-life wishes with patients. With a financial incentive, authors of the law hoped physicians would take the time to sit down with patients to put their end-of-life wishes in writing and designate a surrogate decision maker in the event that they become incompetent.

While uproar equated this with "throwing granny off a cliff," the provision was eventually removed in order to get Obamacare passed. Every congresional session since, Blumenauer has reintroduced the bill, which would reimburse physicians a few hundred dollars to talk to patients about the care they want every five years, or more often, if the patient's health declines. To provide a sense of perspective, Blumenauer notes that with great frequency, tens of thousands of dollars are reimbursed by Medicare for giving terminally-ill patients in their 90s hip replacements.

It's important to note that having the conversations Blumenauer would like reimbursed won't necessarily deter that terminally-ill 90-year-old from getting his or her hip replaced. If a patient wants aggressive care until the very end, that wish would be documented by the physician, and would be more likely to be honored by a surrogate decision maker. The conversation is about making patient preferences clear and well-known, not about doctors steering patient preferences.

"We have allowed people with ideological or political agendas to play this out," Blumenauer told Politico. "We've really obscured the fact that this is all about making an informed decision that is respected."

Now, with the bill independent of Obamacare, Blumenauer has even made an ally across the aisle. Tennessee Representative Phil Roe, a Republican who staunchly opposed the Affordable Care Act, is now one of 15 co-sponsers of the bill.

Physician Incentives Work

While in theory, conversations about end-of-life and advanced care planning should occur between health care providers and patients with or without an incentive, the extra cash could help.

In a study recently published in JAMA Internal Medicine, researchers led by Dr. Joshua Lakin of the University of California, San Francisco tested the effect of financial incentives on a group of internal medicine residents practicing at the university's medical center. Residents were promised $400 if, as a group, they could have documented discussions of end-of-life issues and designate a surrogate decision-maker with at least three-quarters of patients. In a group of 1,474 patients, end-of-life wishes and surrogate decision makers were documented in 22 percent of files at the beginning of the study, growing to more than 90 percent by the end.

Patients need not wait until financial incentives for doctors exist to initiate the conversation.

"If more people go to their physicians and pastors or whoever they trust and say, ‘I want to have this discussion' … that's also an important thing," Dr. Lakin told Reuters Health.

Medicare Reimbursements Are Not The Only Option

Passing Blumenauer's bill isn't the only way to promote end-of-life conversations, and the bill is far from perfect. If it were to pass, Blumenauer's bill would only reimburse visits scheduled by patients for the purpose of discussing end-of-life care. It wouldn't reimburse for that conversation if it arose from a doctor-patient interaction for another purpose, such as during a preventative care check-up or after a life-limiting illness is diagnosed.

"The problem with Blumenauer's legislation isn't that it goes too far," wrote Ezra Klein, columnist for The Washington Post. "It's that it doesn't go nearly far enough."

New York state has taken its own approach. In 2010, the New York Palliative Care Information Act was passed, which mandates that healthcare providers offer information and counseling about palliative care to terminally-ill patients or their surrogates; breach of the law is punishable by a fine.

Bioethicist Dr. Ezekiel Emanuel offers some alternatives to Medicare reimbursement of end-of-life conversations. The Joint Commission, the independent organization that accredits hospitals, could require that palliative care services be available to patients. Even Medicare could make communication training and palliative services a requirement in hospitals for reimbursement of other services.

Whatever the approach, the time is ripe for reshaping the way the public views death and dying. As Blumenauer notes, the issue is becoming more culturally salient. More books and memoirs are written about care-giving and death.

With trendsetting baby boomers aging fast and their parents aging faster, end-of-life conversations will inevitability become more commonplace, with or without reimbursement.

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