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Palliative Care, Advance Care Planning Conversations Needed Between Patients, Hospitalists


Editor’s note: In July, SHM board member Howard Epstein supported the new CMS proposal to pay for advance care planning, calling it a “procedure” for hospitalists. Below are excerpts from his blog post. For the full post, click here.

Last week, the Centers for Medicare and Medicaid Services (CMS), the nation’s largest payer of healthcare services and the 800-pound gorilla in setting medical necessity and coverage policies, announced a proposal to begin paying for goals of care and advance care planning (ACP) discussions between medical providers and patients. Sound familiar? It should. This is the same, seemingly no-brainer proposal that in 2009 was stricken from the eventually approved Patient Protection and Affordable Care Act (PPACA, aka the ACA, aka “Obamacare”) in response to the intentional and patently false accusations of government-run “death panels,” in the hopes of salvaging some measure of bipartisan support. As we all know, the bill eventually passed the following year without a single Republican voting in favor in either the House or Senate, and without funding for ACP sessions!

The need for ACP and access to primary and specialty palliative care is so great and accepted in the healthcare community. In their Choosing Wisely recommendations, numerous medical specialty societies, including ACEP [American College of Emergency Physicians], AAHPM [American Academy of Hospice and Palliative Medicine], AGS [American Geriatrics Society], and AMDA [The Society for Post-Acute and Long-Term Care Medicine], have included early and reliable access to palliative care and avoidance of non-value added care, such as placement of feeding tubes in patients with advanced dementia, calling out the gap between quality, evidence-based, patient and family-centered care, and “usual care” (e.g. medical and disease-focused care) that patients receive too often near the end of life.

So where is the disconnect between what people want and what actually happens to them at end of life?

The answer is clear: We’re not having “The Conversation.”

And, though our primary care and even specialty care colleagues are involved regularly in the care of these patients, they may be inclined to postpone or avoid ACP with patients and families in the outpatient setting due to lack of comfort [or] skill or even recognizing that the person they’ve been trying valiantly to cure or at least prolong the inevitable [for] is on that downslope of life we all eventually experience—it’s called dying.

Our current reimbursement system throws another barrier in front of providers. Like many other “nonprocedural” activities, ACP is not only undervalued; there is currently a lack of value assigned to this important cognitive, empathic, and communication-based “procedure.” And I refer to it as a procedure because, like a surgical or invasive vascular procedure, when it goes badly, the consequences and sequelae can be just as damaging, and even irreparable.

Thus, intentionally or not, the can is kicked further down the proverbial road until the patient reaches the hospital in a state of crisis—sometimes in extremis—and the hospitalist is left to make sense of all the clinical, emotional, psychological, spiritual, and frequently familial history (baggage?) leading up to that hospital admission. We are expected to develop instant rapport and trust while simultaneously attempting to develop (in collaboration with our specialty care providers and, preferably, the patient’s primary care provider) a plan of care that takes into account the personal values and treatment preferences for that individual within the clinical realities of the patient’s illness and disease trajectory as they lie before us.

Sound familiar?

For the full blog post, including Dr. Epstein’s recommendations for what hospitalists can do to support the CMS proposal, visit Hospital Leader.

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