Six years ago, a proposal for Medicare to cover end-of-life counseling touched off a political uproar on “death panels” that threatened to stall President Obama’s health care law in Congress.
When Medicare finally announced Wednesday it will make the change, reaction was muted.
Dr. Joe Rotella, chief medical officer of the American Academy of Hospice and Palliative Medicine, called Medicare’s move a “little miracle,” given the “death panels” furor of several years ago.
He said he believes the controversy has passed. “I think society’s going to get over it this time and see the good in it,” said Dr. Rotella. “It’s really about living in the way that means the most to you to the last moments of your life.”
Interested parties will have 60 days to comment on the new regulation before it is finalized.
Years earlier, former Alaska Republican Gov. Sarah Palin warned about government-sponsored “death panels” dictating the fate of frail elders.
This claim was largely discredited, but end-of-life counseling remained politically radioactive for the Obama administration.
The original sponsor of the idea, Oregon Democratic Rep. Earl Blumenauer, was taking no chances in seeing it through. Just a few weeks ago at the White House congressional picnic, Mr. Blumenauer said he personally lobbied senior officials, handing out pocket-sized cards with his talking points.
“There was a time when the federal government could have been a leader on this, but now it’s basically responding to where the rest of America is going,” he said.
The policy change, to take effect Jan. 1, was tucked into a massive regulation on payments for doctors.
End-of-life counseling is intended to be entirely voluntary for patients.
Some doctors already have such conversations with their patients without billing extra, and certain private insurers have begun offering reimbursement.
But covering the talks with roughly 55 million Medicare beneficiaries is significant: About three-quarters of the people who die each year in the U.S. are 65 and older, making Medicare the largest insurer at the end of life, according to the Kaiser Family Foundation.
“As a practicing physician, and a son, and someone who has dealt with this in his own family, I would say these are discussions … that are critical to high-quality care,” said Dr. Patrick Conway, Medicare’s chief medical officer. “I would want any American who wanted to have this conversation with their clinician to have the opportunity to do so.”
Medicare is using a relatively new term for end-of-life counseling: advance care planning. That’s meant to reflect expert advice that people should make their wishes known about end-of-life care at different stages of their lives, as early as when they get a driver’s license.
The counseling aims to discern the type of treatment patients want in their last days, with options ranging to care that’s focused on comfort to all-out efforts to resuscitate a patient.
The American Medical Association praised Medicare’s decision. “This issue has been mischaracterized in the past, and it is time to facilitate patient choices about advance care planning,” said Dr. Andrew Gurman, the group’s president-elect.
Before Mrs. Palin ignited the “death panels” outcry, there was some bipartisan consensus about helping people to better understand their end-of-life choices and decisions.
A 1992 law passed under Republican President George H.W. Bush requires hospitals and nursing homes to help patients who want to prepare living wills and advance directives.
Similar efforts gained resonance after the 2005 death of Terri Schiavo, the brain-damaged Florida woman whose family fought for years over whether she would have wanted to be kept alive in a vegetative state.
Then-Florida Gov. Jeb Bush got embroiled in the family’s ordeal, ordering feeding tubes reinserted for Schiavo against her husband’s wishes. The husband ultimately prevailed in a legal battle with Schiavo’s parents, who wanted her kept alive.
In 2008, a year before debate over the Affordable Care Act spiraled into tea-party protests, Congress overwhelmingly passed legislation requiring doctors to discuss issues like living wills with new Medicare enrollees.
That bipartisanship dissipated almost instantly when Mrs. Palin said the provision on end-of-life conversations in the Obama administration’s health care legislation would result in bureaucrats deciding whether sick people get to live.
That language was ultimately removed.
Nothing in the recently approved Medicare discussions will be focused on cost, but many experts believe if patients truly understood their alternatives, and doctors listened to them, bills would inherently go down.
A landmark report last year from the Institute of Medicine (IOM) found that few people make their wishes known, and go on to experience breathing machines, feeding tubes, powerful drugs and other treatments that fail to extend life and make its final chapter more painful and unpleasant.
The IOM report was called “Dying in America,” and the institute — an independent organization that advises the government — has a section on its website distilling the issues for families.
Supporters say counseling can give patients more control, and free families from tortuous decisions. Even so, there are often no simple answers. Patients may want less invasive care if they believe they will soon die, but predicting when death will happen is notoriously inexact. Terminal patients can live for years, potentially complicating a choice of less intensive treatment.
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Sedensky reported from West Palm Beach, Fla.
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Online:
“Dying in America”: https://tinyurl.com/o7zb4p8
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