The Physician-Focused Payment Model Technical Advisory Committee is recommending to the Department of Health and Human Services (HHS) creation of a palliative (comfort) care model for Medicare recipients who are in advanced states of illness, but not yet ready for Hospice care. These patients reportedly comprise 4% of Medicare beneficiaries, yet account for 25% of annual Medicare expenditures. The purported goal of this proposal is to better allocate our health care dollars as well as improve care for the acutely ill.
In this column I have stressed that more medical care does not necessarily equal better care in the US. We are blessed to have access to some of the most sophisticated medical-technological interventions available. They can be life-saving. They can also be life-extending, but result in painful, low quality life for patients.
What is unique about this proposal is that it includes financial incentives to providers who participate in the process. Under two proposed models, doctors, nurses, and spiritual providers would work to develop and implement a care programs for those in advanced states of disease. "You have to provide sufficient payment to deliver high quality interdisciplinary care," according to Dr. Phil Rodgers, who helped developed the model.
There are some who argue that practicing good medicine should be incentive enough and additional payments should not be necessary.
Since we are already spending nearly 18% of our GDP on health care, it can be argued that we definitely do not need to spend more. However, health care in our society is monetized in a capitalistic “for profit” approach. Therefore, to encourage certain behavior, the providers need a financial incentive. If the result is a net savings as well as improved care, then the system is satisfied.
A 2016 piece written by Dr. Bruce Bartlow of Shasta Critical Care Consultants titled “Ethics of ICU Care for the Elderly” addresses this topic in great detail. The article examines the ethical aspects of how we care for our acutely ill patients.
His premise is consistent with the proposed rules in that it argues that we must be attentive to what results in the best quality of life for the patient. He examines the ethical dilemas that face the children of the elderly as they change roles into the role of caretaking an elderly parent. He shares his experience of the ways in which an individual will change their directions to the physican when the cost comes from their own pocket rather than Medicare or other insurance..
He explains that many people create an Advanced Directive believing that solves the problem of informing their families and physicians of their intentions for end of life care: “ Many AD’s spell out what appears to be a DNR (Do Not Resuscitate order) as follows: “I do not wish life sustaining measures if (a) the burden outweighs the likely benefit, (b) I have irreversible coma, or (c) it will only delay my death.”
When patients sign this, very few of them or their surrogates realize that: (a) They have no idea what burdens (risk, suffering) are headed their way, nor have they begun to consider what amount of damage would be acceptable for what outcome (benefit, quality of life); (b) irreversible coma usually takes weeks to months to predict, and (c) every breath we take delays our death. At precisely what point do we conclude those breaths are no longer in our best interest?”
Health care providers are uniquely positioned to assist families at this critical time if they are well informed. In fact in his own practice Dr. Bartlow proceeds in this manner. “I begin end of life (EOL) discussions, “I’m not asking you to decide if your mother/father lives or dies. Their illness will decide. I’m asking you to tell me what they would be saying if they could: how much they would want me to put them through to attain what quality of life, and what scene they would want at the end. Then I can tell you what I can achieve. If the best I can do is a death they would have hoped for, I’ll tell you how we can get there.” After they get over the shock that it’s not their, but their parent’s choice, almost uniformly they appreciate having the burden lifted.”
It is intriguing to me that that we are not hearing any reporting labeling these proposals as “death panels” like we did during the implementation of the ACA (Affordable Care Act, aka Obamacare). The ACA simply included provisions that would pay a primary care provider for having “end of life issues” discussion with a patient as a standard office visit. It will be interesting to see how this action is characterized as the discussion proceeds.