Billing for end of life conversations needs to be an honest discussion

Good old Earl Blumenauer.  A bespectacled and bowtied Congressman from Oregon.  He of the “death panel” proposal.  Thank God he’s still here.  Presuming that the crazy talk over the provision in the Affordable Care Act that would have paid doctors to discuss end-of-life issues with patients is over, he has introduced a separate bill with this provision and hopes to get it passed in the next couple of years.

What Congressman Blumenauer is proposing is really to validate conversation by providing it with a monetary value.   Everything that is valued in medicine has a monetary value.  In anesthesia the value of time is monetized in increments of 15 minutes.  There is no more relevant data in the electronic medical record than the start and end times.  Multiple emails go out daily from our two full-time coding folks if the start time of one case overlaps with the end time of another.   Not because they want the times to be accurate.  Because they want to bill.  You can’t bill for curbsides.  You don’t bill for answering the phone.  You don’t get money for answering patient email.  Communication is not valued, in the sense that it is not assigned a monetary value.  Thus, it doesn’t happen.   If this bill, provided it passes, is going to provide legitimacy and value to having an honest conversation within the context of medicine, I’m all for it.

That’s as long as it is an honest conversation.  Paying people to do something produces far different results than people doing the thing because it’s the right thing to do.  I pay my cleaning lady to clean my house.  She only cleans my house because I pay her.  The more houses she cleans, the more she gets paid.  So her focus is on how quickly can she clean my house, not necessarily on how well  she can clean the parts of my house that matter, like the kids’s bathroom or the kitchen.

I could clean my house, without pay, because it needs to be clean.  I won’t do it quickly (or with much grace) but I will focus on the parts of the house that matter the most to me.  Same with advance directive conversations.  As a doctor, I can observe that this particular patient needs to have this conversation, and because I see the need I do it, focusing on the parts that are of most concern to this particular patient.  If I’m paid to have this conversation, or it becomes attached to rewards and penalties, I may be tempted to develop a template or routine that prompts me to cover everything I need to cover and ask all the questions on the list but not the ones the patient necessarily cares about.

Because once you can bill for something, someone can start requiring it, measuring it, and regulating it. Once you can bill for something, it quickly becomes another check box on someone’s computer program and usually ends up on an ever-increasing pile of quality measures.  Once it be becomes a quality measure, it starts getting tied to performance reviews, rewards and penalties, and yes, money.  I sincerely hope this doesn’t happen, but the trends do not bode well.  If the bill passes.  The trends don’t bode well for this either.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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  • Guest

    My lawyer is the one who brought up having an Advance Directive, at the same time as I was having him do my will. He gave me the booklet from the Florida Agency for Health Care Administration and the Florida government website address where they’ve got templates and explanations, and we just tweaked the standard forms a little and I had a Living Will and a Healthcare Surrogate form signed and witnessed along with my regular will.

    I don’t have just one doctor anymore, I have a “team of healthcare providers”, none of whom I know very well, so I didn’t bother getting a doctor (or nurse, or PA, or physical therapist, or nutritionist, or whichever random “provider” I would have ended up with had I bothered making an appointment and going in) to go over it with me. The free brochure and website were pretty self-explanatory.

    I’m surprised the ABA hasn’t lobbied to be the ones to get paid to have these “free” discussions with citizens, rather than the AMA. Throwing “free” taxpayer dollars around is like putting chum in the water.

    • Shirie Leng, MD

      Very good point. I hadn’t thought of this as being a lawyer’s job but in a way it makes sense. The lawyer is paid to spend time with you and talk to you for as long as you need. The only thing they don’t have is the medical knowledge, which for advance directives might or might not be necessary, depending on the person.

      • Rachel

        If you are supposed to be explaining what it means to be on a ventilator, wouldn’t the patient want someone who actually understands how a ventilator works, and what it means for the patient? A lawyer cannot do this.

  • petromccrum

    Why does everything have to be legislated anymore? We need to go back to the days of NO health insurance and patients being billed for the true cost of services rendered. Doctors would be able to bill for time spent with patients not some ridiculous, cumbersome method that makes no sense to anyone.

    • John G.

      “Why does everything have to be legislated anymore?”

      Apparently doctors either cannot or will not perform the basic tasks of doctoring anymore without specific legislation telling them they must. They’re enamored of becoming taxpayer-funded and government-controlled drones.

  • Nancy True

    I’ve served as a Clinical Chaplain in Hospice Care for 10 years
    and I’m glad to hear Rep. Blumenaur has stayed the course to propose needed
    support for advance medical care decision-making. It’s time we separate end of life decision-making
    from end of life. Preparing for medical decisions can be integrated with the
    preventive measures already in place. The
    points you make in your article reflect both the difficulties of having
    meaningful conversations with multiple healthcare providers and our culturally
    embedded fears of illness and dying, (I’ve met many people who are fine being
    dead, but it’s getting there that trips everyone up!). Current practices actually
    have people filling out a form without documenting what their medical
    preferences are and how they want to be treated. The time is now and the
    solution is available, Doctors don’t have to be the only ones who have these
    face to face conversations. Clinical Chaplains are trained and accomplished in
    these initial and ongoing conversations with people about their healthcare
    choices in treatment and care before and after they become patients. Clinical
    Chaplains can work in community based settings in similar ways they serve in
    hospitals. Healthcare services “upstream” from end of life care can take
    a lesson from the interdisciplinary team model of Palliative Care and Hospice
    Care services.

    • Guest

      It’s hardly surprising that the folks who would score this big taxpayer bonanza would argue in favor of it. Everyone wants a slice of the pie.

      Blumenaur has promised to rob Peter to pay Paul, and you’re Paul.

    • Shirie Leng, MD

      Thank you Nancy. Very important resource.

  • Rachel

    But, Dr Leng, your anecdote proves the point of why we need the bill- you currently are not the one who cleans your house because your time is better spent doing other (revenue generating) things

    • Shirie Leng, MD

      Rachel – Ha! True but since I’m mostly a stay-at-home mom not much I do generates revenue… :)

  • Dorothygreen

    Perhaps a so-called “death panel is a better idea. However, it should be called a “let a person live his last days with dignity” Having an advance directive is only part of the end of life issue. Here is a scenario far more common than the Terry Shrivo situation.

    An 83 yr old with a prior stroke, bad balance and other assorted age related issues went through the following end of life sequence

    He fell and broke his hip, had surgery, doctors an found arrhythmia, a pacemaker was put in, he went to rehab, back to ICU in 2 days with “double” pneumonia.

    Jack Lelane went home to die when he developed pneumonia after surgery at 96.

    No, my acquaintance could not get out. He may have had an advance directive that said the usual:no CPR or tube feeding, His daughter was with him. His condition go worse quickly even with antibiotics. A ventilator was next, Heavily sedated and intubated, he had no say.

    A good friend say he woke and pain was apparent on his face. She knew, maybe his daughter knew too but there were the physicians insisting that these were the thing to do.. Dialysis was started. Two days later a collapsed lung. “We need to put a tube into his chest” a physician said. “NO more!” his daughter said and in retrospect was chiding herself for waiting so long. He died shortly thereafter.

    Is a discussion with a physician about an having an advance directive going to change this scenario?. Probably not. But, a lot more public education, easy access to a standardized form (5 wishes comes to mind) and using social workers, registered nurses or other folks as “certified advance directive counselors” would be far more cost effective. The medical community or someone needs to monitor physician behavior in end of life situations. Not only did this person suffer needlessly but the hospital and physicians bills to Medicare will be be needlessly enormous

    I know my acquaintance would not have wanted this.

    • Guest

      “an advance directive that said the usual:no CPR or tube feeding,”

      If your friend had signed a basic Living Will template, available freely on the internet from a variety of sources, he probably would not have been put on a ventilator. What you call “the usual”, is not. Here is “the usual”:
      * * * * *

      I, ____________________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am mentally or physically incapacitated and

      _____ (initial) I have a terminal condition,


      _____ (initial) I have an end-stage condition,


      _____ (initial) I am in a persistent vegetative state,

      and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

      I do ___

      , I do not ___

      desire that nutrition and hydration (food and water) be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying.

      It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

  • Mark Hilditch

    I appreciate your concern about the legislation causing these end of life discussions to fall far short of an ideal. But, let’s get realistic here, to have these legislated, paid, perfunctory discussions is way, way better than not having them at all – which is still the vast norm in our death-denying culture. This legislation would at least be a place to start.

    • Shirie Leng, MD

      OK Mark, true, but can’t we start somewhere else?

  • katerinahurd

    Can you explain how one bills for quality? I assume that monetary value is assigned to quantities. The only quantifiable parameter is the time spent between the patient and their physician. According to the adage, time is money, I would infer that you bill for the time spent with your patient. No mention about how you assign monetary value to the quality of time spent.

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