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Posted by on Jul 9, 2015 in Health, Politics | 22 comments

(Updates) Medicare-Covered End-of-Life Counseling Proposed



The New York Times, Los Angeles Times and other news sources are providing additional details on Medicare’s plans to reimburse doctors for “conversations with patients about whether and how they would want to be kept alive if they became too sick to speak for themselves.”

New York Times:

“The new plan is expected to be approved and to take effect in January, although it will be open to public comment for 60 days.

Medicare’s plan comes as many patients, families and health providers are pushing to give people greater say about how they die — whether that means trying every possible medical option to stay alive or discontinuing life support for those who do not want to be sustained by ventilators and feeding tubes.


[Dr. Patrick Conway, the chief medical officer for the Centers for Medicare and Medicaid] said a final decision on the proposal would be made by Nov. 1. The plan would allow qualified professionals like nurse practitioners and physician assistants, as well as doctors, to be reimbursed for face-to-face meetings with a patient and any relatives or caregivers the patient wants to include. Dr. Conway said the proposal did not limit the number of conversations reimbursed.


The reimbursement rate paid under the proposal and other details will be determined after public comments are received, Dr. Conway said…

…Some private health insurancecompanies have recently begun covering such advance care planning conversations, and more are likely to do so once Medicare formally adopts its new rules.

As a big part of the American population ages, and more people live longer with grave illnesses, a growing number of people want to be able to talk over options with their doctors — deciding, for example, whether they want to die at home or in the hospital, or under what circumstances they would want life-sustaining treatment.


Filling out advance directives can help, and some states have created central databases of these forms so they are easier for a patient’s doctor or specialist to find in moments of crisis. But end-of-life experts, and the members of the national panel, said simply checking boxes on a form was of limited value because many patients needed several conversations to consider their options and to talk them over with their families.

The Los Angeles Times:

“The new proposal from the Department of Health and Human Services would not require Medicare patients to sign any order or even to talk with their physicians about end-of-life care.

Rather, the proposed regulation would allow medical providers to bill Medicare for “advance-care planning” should a patient want to have the discussion.

Such a session could include “the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health professional,” according to the proposed rule.

Original Post:

It is natural for those of us with sixty, seventy or more years of living under our belt to think, even worry, about what those last years on this planet will be like and perhaps do some planning and make some decisions on how we would like to spend those “golden years.”

Some call this natural interest “end-of-life planning.”

Since we already have a program that deals with health care needs for senior citizens — called Medicare — it follows that such end-of-life planning should fall within the purview of that program.

Moreover, since most Americans finally have a program that also deals with health care issues of both the young and the old, called the Affordable Care Act (ACA), perhaps it might have been a good idea to include such end-of-life planning aspect in that program.

Thanks to Conservatives led to battle by none other than Sarah Palin under the false battle cry of “death panels,” such provisions were not included in the ACA.

Readers might well remember the shamefully false demagoguery by Palin, echoed by many other prominent Republicans, five or six years ago, that not only killed any possibility for covered end-of-life planning under Obamacare, but also “spelled the end of a proposal for Medicare to reimburse doctors for voluntary end-of-life consultations with patients.”

Well, six years later, although repeatedly proved to be false, perhaps the myth of those death panels is being shown for what it is: a myth, a lie.

The New York Times reports today:

After years of debate about whether the government should encourage end-of-life planning — an idea that Sarah Palin claimed would lead to “death panels” cutting off care to the sick – Medicare, the federal program that insures 55 million older and disabled Americans, is now proposing to reimburse doctors for having conversations with patients about whether and how they would want to be kept alive if they become too sick to speak for themselves.
This new policy, announced Wednesday, comes at a time when patients, families and health providers are placing greater emphasis on allowing people to choose the way they die – whether that means trying every possible medical option to stay alive or discontinuing life support for those who do not want to be sustained by ventilators and feeding tubes.
Efforts to support end-of-life planning were derailed during the debate over the Affordable Care Act. In 2009, Sarah Palin labeled a plan to include doctor reimbursement for advance care planning conversations under the law as tantamount to setting up “death panels,” effectively killing the provision. The next year, Medicare decided through its regulatory powers to allow coverage for “voluntary advance care planning” in annual wellness visits. But soon after, the Obama administration capitulated to political pressure and rescinded that part of the regulation.

In contrast to Justice Thomas’ “dignity” of slavery argument, such a new Medicare provision should be called “Dignity at the End of Life.”

Read more here.

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  • When I signed my late mother up for home hospice I had to go through end of life counseling if Medicare was going to pay for it. It was very good and they told me what to expect and the accuracy was amazing. It made the transition much easier. I had already done most of my grieving when she passed away and I could better deal with the estate issues.

    • Slamfu

      My father passed away last February after wasting away in a bed for 4 years following a massive series of strokes. End of life counseling was EXTREMELY helpful, and up until we got it I didn’t even know that was a thing. Those are good people doing some soul crushing work, day in and day out, to make life easier for others. God bless them.

      • archangel

        Thank you Slamfu for telling us this about your and your father’s life, and God Bless you also.

    • archangel

      This is excellent info Ron. Did they give you any written materials? Thinking of you and your mom and the good watching over her that you did Ron.

  • dduck12

    Advice, don’t wait for the government to do later life planning or for that matter any planning. Start all planning yourself, and consult professionals experienced in the pertinent field. Now, just for later planning:
    Do make sure you and yours have health care proxies,, wills and living wills.
    Consider Long Term Care Insurance (LTCI) for yourself and older relatives. Yes, it looks expensive, and is, but the alternatives may not be pretty.
    Think about how you could/would handle the need for extensive nursing care with a mind to staying at home as the first priority (oh, those stairs or a bedroom for the nurse, bathing, and more) and then some kind of facility. If you are older, go check some facilities out as my wife and I have done. You may have preference which you could communicate to others, especially if you are out of it. In other words plan ahead, instead of sticking your head in the sad.
    Cheerful lecture now over.

    • DdW

      Advice, don’t wait for the government to do later life planning or for that
      matter any planning. Start all planning yourself, and consult professionals
      experienced in the pertinent field.

      I believe that it is not the government that will be doing the “planning,” dduck, but rather those (medical, etc.) professionals you mention. The government would just help people defray those expenses.

      All your other advice is excellent and pertinent. Thank you!

      • Exactly, the end of life counseling I had for my mother was by her primary care physician and the hospital that was going to be the service provider.

      • dduck12

        No, you need to start the ball rolling, the government will not. Expenses are yours, no free lunch.

        • My late mother had a living will but when I signed her up for Home Hospice Medicare required that I have counselling which was done by medical professionals. I had to agree to nothing that was not in her living will. This law is simply about Medicare paying medical professionals to supply the counselling. It’s the private insurance companies hat have “death panels” when they refuse life and death tests

          • dduck12

            My mother was under hospice care, and I loved it and the people.
            I encourage people to do planning BEFORE they have a dire situation.

          • archangel

            Hospice people are more often the people who actually understand pain management, compassion, care of the family as well as the person who is in leavetaking FAR better than most docs who are in the other end… trying to keep people well and alive.

    • SteveK

      Thanks dduck12 sound advice and I’m glad you included a Nolo Press link.

      Most people that can turn on a computer, log on to the internet, and print a document can get their act together using Nolo.

      Their “Online Living Trust” costs $60.00 (currently on sale for $42)

      Edit: Nolo has removed the will from their trust product and made it a separate item. cost $35 (currently on sale for $25)

      It gives you everything you need to create a will; living trust; assign trustee(s) and designate trustor(s); change titles to home(s) and vehicles(s); etc. etc. etc. All forms are state specific and you get unlimited revisions for a year. I was done in less than 4 hours (not counting time at the notary, bank and motor vehicles) and if I could do it anyone can.

      You enter your information and intent in plain English and the Nolo program adds the required legalize to make it a valid document without making it impossible to read or understand.

      • dduck12

        Caveat: I only linked to NOLO because they had a laundry list of planning tools. I am not advocating them or the use of self help documents, unless you have no other access to professionals and/or to just get the planning ball rolling.

        • SteveK

          @ dduck12 – I understand, and I understand your advocating that everyone use a ‘planning professional’… This is why I was pleasantly surprised that you mentioned NOLO.

          I look at it as:

          I have a Living Trust / Will / Advanced Directive that my state, my Bank, and Motor Vehicles acknowledge as valid documents… It cost me $30 and eight hours’ of my time.

          My brother had a professional draw up these documents for him… It cost him $4,500.00.
          And every year he gets a phone call and letter telling him he ‘has to come in’ for a $275.00 review to make sure that nothing’s changed.

          Note: My brother is 73 and he thinks (knows?) that the next ‘change’ in his trust will be when his trustor starts settling his estate.

          Edit to add: dduck12 and I both agree that everybody needs to address their end of life planning.

          There are many ways of doing this and my comment was not meant to make light of the service that planning professionals provide. Most people would probably do nothing were it not for their services.

          My comment was meant only to show that if you’re curious, comfortable learning something new, and have a little time on you hands you can really, really save a LOT of money.

    • shannonlee

      well done… people need to think about this stuff… start planning and get control.

      Despite best intentions… some doctors will torture a patient in an attempt to save their life… even with a 1% chance. We just went through this with my wife’s father who just passed.

      Also, dont just trust doctors! get multiple opinions and get informed.

      • Slamfu

        Amen to the not trusting doctors part. We had a DNR for my dad for a long time, and yet each time the doctors would ignore it. My brother and I having just got to the hospital after he had a major issue walked into the room to find the doctor on duty discussing and prepping my nearly comatose, deranged father for a pacemaker implantation! I can’t use the language I’d like to even just summoning up the memory, but I no longer trust doctors either. Second opinion for sure, because you are just a piece of meat to them.

        • JSpencer

          In a similar vein, I wonder how often doctors tweak end of life decisions elderly people have made by prescribing medications that interfere with clear decision making. If one no longer cares about how long they linger or in what state, then the decisions have been wrested from you.

        • shannonlee

          pacemakers payout pretty well for hospitals… probably what they were trying to do… we had the same type of stuff happen to us.

        • Sal Monela

          My family had a different sort of experience. My 90 year old dad, who is still very sharp, stopped eating saying that he just couldn’t tolerate food. We took him to his doctor who told him contact hospice and go home and die. His condition worsened so my mom took him to the ER. Turned out that he had a blockage that was easily corrected and he immediately regained his appetite. This occurred a year ago and he his still alive and well. My point is that if you or your loved one has a will to live don’t be too quick to give up or let your doctor give up on you.

          • archangel

            life is sacred. I love this father of yours, and your family that was so wise in this case. Alive and well is the hope for most everyone. May your dad continue in good health and clear mind for a long time to come. We have had elders pass in their late 90s, clear as a bell, strong, and also at the a certain time, they slipped away. And each day of life was for the living of life in whichever way within reach.

          • Sal Monela

            Thanks so much for your kind words. My dad is a real treasure.

        • The_Ohioan

          My brother-in-law had the same experience with his dad. The doctor completely ignored his dad’s and his wishes. My brother-in-law and his wife filed an official complaint with the hospital and made sure the hospital followed up on it. I don’t know if doing the same would ease your pain or make it worse – just offering.

          They wouldn’t have had as much influence, unfortunately, had his father not been an important former Michigan government official. And I don’t know if the doctor changed his MO.

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