As an intern admitting emergency- room patients to a Cincinnati hospital, I saw it happen again and again: Late-stage cancer patients in the midst of medical crises would roll into our ER in need of a ventilator as expected complications mounted.
We would ask for their advance directives, who had their power of attorney, and whether they had considered “do not resuscitate” orders or hospice. Too often, these concepts were unfamiliar, even for patients who had been undergoing cancer treatments for months or years.
If it ever makes its way out of Congress, a bipartisan bill introduced this month in the Senate Finance Committee would correct some of the structural problems that lead to this sad and costly phenomenon. For too long, American medicine has pushed off the big conversations with the sickest patients until too late.
Coming to terms with such weighty decisions in an ER bay or with loved ones hovering around a bed in the intensive-care unit is too late, especially when a deadly diagnosis is known well before the hospitalization. Once the patient is “sedated and intubated” and the family is in shock, the most valuable window into the patient’s true desires has been lost. When patients haven’t had the chance to wrestle with their values in the context of all their options and haven’t talked out their preferences before their critical-care scenario begins, their families will make aggressive choices on their behalf.
Sen. Mark Warner, D-Va., the driving force behind the Care Planning Act, experienced these same pressures during his mother’s declining years. Warner’s bill, co-sponsored with Sen. Johnny Isakson, R-Ga., identifies the need for a detailed, structured discussion between the patient and their health-care providers, family, friends and other support such as faith leaders - a discussion Warner’s family never had with his mother.
The reason, as is so often the case in health care, is what gets paid for. Such meetings, while of enormous value to the health-care system as a whole, have never had a corollary in professional billing, meaning it often doesn’t occur. The result is bewildering tales like those from the Cincinnati ER, where many of my patients on life support never had the option to choose hospice instead of the ICU. In fact, a 2010 study of 325 terminally ill cancer patients found that only 39 percent had discussed their end-of-life care choices with their oncologists.
The Care Planning Act would create a billing code for “planning services,” allowing physicians to charge for these lengthy and challenging sessions with patients and their extended support networks. The legislation goes on to require that the meeting result in a documented plan.
That’s critical. I once cared for a woman much like Warner’s mother, suffering from dementia, who came into my care in a rehabilitation hospital screaming in pain. The cause was immediately evident: She had an unset bone fracture that the family, in consultation with the orthopedic surgeon at the referring hospital, had decided not to treat due to her age, frailty and dementia.
So why, I had to ask, was she referred to the acute rehabilitation hospital, where our therapies would cause her more suffering and where our services typically cost Medicare four times those of a skilled-nursing facility? To be effective, plans resulting from the Care Planning Act must anticipate the impact that crucial decisions - such as whether to undergo major surgery - will have on downstream care choices.
Warner and Isakson aren’t advertising their bill as a cost- containment measure, in deference to that peculiar vein of American politics that once called end-of-life care coordination a “death panel” and got it excised from the Affordable Care Act. But this bill would indeed contain costs while providing the care that patients want, and that’s an important reason to support it.
About one-quarter of all Medicare spending in 2006 went to caring for patients in their last year of life, and much of that tab is run up in the last week. The more money we spend in that week, the lower patients and families rate their quality of life, studies show. A 2009 study of advanced-cancer patients found that those who participated in end-of-life discussions with their physicians spent 36 percent less on medical care in their final week and experienced a better death than patients who didn’t get the benefit of such counsel.
Economics drives medicine more than we care to admit. Oncologists who are paid by procedure (rather than salary) or who work in capitated-care models will spend four to six minutes less of their already limited time on each patient visit. The physician’s role in facilitating complex care coordination has been undervalued to such an extent that doctors can’t even bill for it, and that’s resulted in a system burdened with unnecessary costs.
When patients get the information they need from their providers, such as the fact that only 10 percent of patients who survive in-hospital cardiac arrests ever make it back to their community, they make more conservative care choices that they find more satisfying and allow the system to provide better care for more people. Statistics show that patients who spend more time with their outpatient physicians during their final year end up spending fewer days in the hospital, and they are more likely to die at home.
The Care Planning Act would give more of these patients the time they need with their physicians, improving life in the pivotal last year for hundreds of thousands of seriously ill Americans every year. So the fact that the bill’s sponsors won’t cite cost savings as a reason for passage demonstrates the political paralysis that’s still being inflicted by such buzzwords as “death panels” and “rationing” in the face of reason and experience. For the sake of patients and the health- care system, it’s time to get over it.
Ford Vox, a doctor at the Shepherd Center for brain and spinal-cord injury in Atlanta, writes about health-care policy.