Pay to Plan

When Medicare began allowing payment to physicians for advance care planning on January 1, bloggers and editorialists and columnists all commented on the new rule. Many said what a great new advance this is. Dr. Diane Meier, founder of the Center for the Advancement of Palliative Care, said it was “substantive and symbolic.” Others were more guarded. Dr. Robert Wachter of the University of California San Francisco said he expected a “modest uptick” in the number of advance care planning conversations, but did not anticipate the rule would be “transformative.” Now, an essay in Health Affairs pulls together the various comments and critiques and concludes that unless we overcome the prevailing “training deficit,” the pervasive inability of physicians to carry out such conversations, and unless we develop a health care system that allows for the implementation of whatever choices patients make, the reform will be meaningless.

The reason I didn’t blog on this topic—apart from the fact that so many other voices were chiming in—is that it seemed obvious to me that the change was exclusively symbolic. It was obvious because the truth is that doctors have been able to bill for advance care planning visits for years. Instead of using the elaborate “coding system” that most doctors use for billing purposes, in which you have to assess the level of complexity of the history, physical exam, and something nebulous called “medical decision making,” it is perfectly legitimate to bill based on time. All you have to do is state how long you spent with the patient (and family) and write that “over 50% of the visit was devoted to counseling.” If you do that, then there are no specific rules about “documenting” the physical examination and the history--your note can focus primarily on the substance of the visit, advance care planning. And you get paid more for a 40 minute office visit using the old system of time and counseling--$145.82 in 2016—than you do for a 30 minute advance care planning visit using the new code--$86.66 in 2016 (though you can also tack on an extra 30 minutes for filling out forms with the new system and bill another $75.11). 

To be sure, to use the old system, the patient has to be physically present. You have to write something in your note about the medical history, but “77 year old retired lawyer with stage 4 non-small cell lung cancer, unresponsive to chemotherapy” is good enough; and you have to write something in your note about the physical examination, but  “patient is pale and cachectic; he is hoarse and dyspneic" should suffice. The remainder of the note can address goals of care, choices about limitations of treatment, designation of a health care proxy, and so forth.

Now I don’t want to underestimate the power of symbols—especially since the effort to include any kind of mention of advance care planning in the Affordable Care Act was dead on arrival after Sarah Palin made her notorious “death panel” comments. But sometimes adopting health policies that are doomed to be ineffective leads us astray because we think we have “solved” whatever problem led to the introduction of that policy in the first place, and result in our failing to solve the problem over the coming years. Perhaps the Patient Self-Determination Act of 1990 was a legislative example of the same phenomenon—as a result of this law, every state and the District of Columbia passed some sort of advance directive legislation over the next decade, but we now recognize that this kind of “legal transactional” approach to advance care planning, rather than a more communications-based approach, doesn’t work: either people don’t use it, doctors don’t follow the directive, or the directive doesn’t apply in precisely the clinical situations that real people find themselves in. 

So yes, Medicare’s decision to reimburse doctors for time explicitly spent on advance care planning is symbolically important. But I worry that it will result in unwarranted complacence, in our checking off advance care planning reform as “accomplished” on our national to-do list. Now that would be a serious mistake.