5 things you should know about Medicare’s new end-of-life discussions

Doctor Stephen Hippler speaks to patients Don and Ruthie Roth at his office in Peoria, Illinois, November 26, 2013. Now, patients are at the forefront of an experiment, under way in Peoria, Illinois, and hundreds of other U.S. cities, that could transform the way doctors, nurses and hospitals deliver care to patients. Amid the barrage of criticism over the rollout of Obamacare, groups known as Accountable Care Organizations (ACOs) are quietly going about the business of testing the potential for healthcare reform. The efforts, born of President Barack Obama's Affordable Care Act, are part of the biggest experiment yet to fix the costly and error-plagued U.S. healthcare system. The new models of care, which encourage providers to form networks to coordinate care and cut costs, involve close monitoring of the sickest patients to address budding health problems before they cause a costly trip to the emergency room or an extended hospital stay. To match Feature USA-HEALTHCARE/PEORIA Picture taken November 26, 2013. REUTERS/Jim Young  (UNITED STATES - Tags: HEALTH POLITICS) - RTX1734B

End-of-life discussions with your physician or other licensed caregiver are now being paid for by Medicare. Talking about your wishes and the kind of health care you want to receive at the end of your life is probably not at the top of your bucket list, but such discussions could be very important. Photo by Jim Young/Reuters

Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.

End-of-life discussions with your physician or other licensed caregiver are now being paid for by Medicare — one of the program’s major consumer changes taking effect this year. Thinking and talking about your wishes and the kind of health care you want to receive at the end of your life are probably not at the top of your bucket list, or anywhere close, but such discussions could be very important.

A big chunk of health care spending occurs in the final months of a person’s life, and it often brings very little benefit. While Medicare covers a lot of these expenses, particularly through its extensive coverage of hospice services, families are also on the hook for a lot of this end-of-life spending. Beyond dollars, the emotional burden of helping a loved one in their final days often is enormous.


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Adding to both burdens, your grown children and other friends and loved ones may not have a clue about the kind of care you would want should you no longer be able to make your own health care decisions. There is, unfortunately, a good chance this will be the case. So creating advance directives and other binding end-of-life health care documents is essential.
There is no guarantee that having end-of-life appointments with your doctor will achieve all these hoped-for outcomes. Doctors may not have such discussions on their professional bucket lists either. You and any caregivers you now have need to invest in this opportunity if it is to succeed.

“For Medicare beneficiaries who choose to pursue it, advance care planning is a service that includes early conversations between patients and their practitioners, both before an illness progresses and during the course of treatment, to decide on the type of care that is right for them,” Medicare said last fall when announcing 2016 program changes.

With this in mind, here is a series of questions and answers about this new program. The questions are mine. The answers are from the Centers for Medicare & Medicaid Services, which oversees the Medicare program.

1) How much will Medicare pay doctors for these visits?

The national payment amounts rounded to the nearest dollar are, for the first 30 minutes, $86 in the office or $80 in a facility setting. In both settings, the caregiver would be paid $75 for an additional 30 minutes.

2) Does this amount represent 100 percent of the visit’s costs, or do Medicare beneficiaries have normal copays?

When provided as a separately payable service, advance care planning is subject to a 20 percent coinsurance as required by law. The statute only allows a Medicare service to be provided not subject to coinsurance and deductible when it is provided as part of a preventive or screening service such as the “Welcome to Medicare Visit” [when a person first enrolls in Medicare] or the annual wellness visit.

3) Can doctors combine these appointments with other patient activity with these other visits?

Medicare will continue to pay for advance care planning furnished as part of the “Welcome to Medicare” visit. In addition, Medicare will pay for advance care planning furnished as an optional element of the annual wellness visit. In all other contexts, Medicare will only pay for advance care planning when the services are medically reasonable and necessary.

4) If the doctor’s office is not familiar with this new benefit, can you provide the names and online locations of any forms that doctors must complete to be compensated by Medicare for these appointments?

The change was included in the 2016 Physician Fee Schedule final rule. Advance care planning services are compensated under CPT [Current Procedural Terminology] codes 99497 and 99498.

5) Can only my doctor provide these planning sessions?

Under Medicare’s rules, advance planning will be covered if provided by “non-physician practitioners,” a group that includes nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM) and physician assistants (PA).

The Conversation Project, a non-profit that supports end-of-life planning and family discussions, has this list of 10 questions. Answer them to see if you and perhaps other family members should take advantage of these new Medicare benefits:

When you think about the last phase of your life, what’s most important to you? How would you like this phase to be?

Do you have any particular concerns about your health? About the last phase of your life?

What affairs do you need to get in order, or talk to your loved ones about? (Personal finances, property, relationships)

Who do you want (or not want) to be involved in your care? Who would you like to make decisions on your behalf if you’re not able to? (This person is your health care proxy.)

Would you prefer to be actively involved in decisions about your care? Or would you rather have your doctors do what they think is best?

Are there any disagreements or family tensions that you’re concerned about?

Are there important milestones you’d like to be there for, if possible? (The birth of your grandchild, your 80th birthday.)

Where do you want (or not want) to receive care? (Home, nursing facility, hospital)

Are there kinds of treatment you would want (or not want)? (Resuscitation if your heart stops, breathing machine, feeding tube)

When would it be okay to shift from a focus on curative care to a focus on comfort care alone?