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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