On a daily basis, individuals of all ages are required to make choices. As children grow into adults, the types of choices that must be made increase in variety and complexity.
Both internal and external factors influence our choices. While some older adults will defer to their adult children when they feel overwhelmed by choices, most value their independence when it comes to decision-making.
A number of articles in this column have addressed choices related to health and long-term care. One of the choices we have encouraged is the drafting of advance directives.
While many people are reluctant to think about this topic because of our culture’s attitudes about declining health and death, nevertheless, this is one method of communicating beliefs and wishes about health care choices during a time when one may not be able to comprehend or verbalize those choices.
Discussions about these types of choices may take place among family members, or between individuals and their health care providers. Sometimes, health care providers may be as reluctant as their patients to discuss these sensitive issues. Part of this reluctance is probably due to a lack of education about how to have these conversations.
Until now, though it may sound crass, another factor that played a role in a physician’s ability to initiate these conversations was money. Physicians are paid based on the care that they provide, and conversation was not considered to be care.
Beginning in January 2016, money will become less of an issue. In September, this column mentioned that the Centers for Medicare and Medicaid Services (CMS) was considering activating two codes within the Medicare Physician Fee Schedule that would allow for physician reimbursement of advance care planning discussions with patients.
CMS, in one of their fact sheets on the topic, describes advance care planning as “a service that includes early conversations between patients and their practitioners, both before an illness progresses and during the course of treatment, to decide on the type of care that is right for them.”
Although these two codes were added to the Medicare Physician Fee Schedule last year, they existed only on paper since they were inactive and had no payment amount associated with them.
Recently, CMS released their final rule on all of the proposed changes to the 2016 Medicare Physician Fee Schedule. One of those changes was the approval of advance care planning as a reimbursable benefit under Medicare Part B. This means that physicians can receive payment for time spent speaking with patients and their families about different options for care and treatment as they relate to end of life issues.
How will this change affect the delivery of care? Hopefully, individuals and families will have the opportunity to become better informed consumers of health care.
Just because a test or procedure is available for a specific condition doesn’t mean that it is appropriate for every individual who has that condition, or that every individual would want that test or procedure. Instead of health care providers dictating an expected course of treatment, advance care planning allows individuals to have greater control over their own lives.
The key is that individuals need to be willing to think about and discuss actual or potential situations and their wishes regarding treatment in those situations. Health care has many gray areas, and while advance care planning cannot be expected to address every potential scenario, discussions allow individuals, family members and providers to establish some basic guidelines. These guidelines can prove invaluable later on if dementia develops or an accident/illness renders the person incapable of continuing to make decisions independently.
Although reimbursement will now be available to physicians, this doesn’t necessarily mean that physicians will initiate advance care planning conversations. Individuals who want to maintain control over their own care should begin to think about the last stage of life while they are still healthy, ask questions of their health care providers if needed, and share their thoughts with loved ones.
Think of advance care planning as a gift that can’t be wrapped. During an otherwise sorrowful time, the peace of mind that your loved ones will have when they know and are able to follow your wishes can provide much needed comfort.