Lawmakers propose incentives for end-of-life planning

NEW YORK Tue May 6, 2014 2:03pm EDT

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NEW YORK (Reuters Health) - If you are one of the estimated 70 percent of Americans who have not documented your end-of-life healthcare preferences, Republican Senator Tom Coburn of Oklahoma hopes a cash incentive will prompt you to do the paperwork.

Under his newly introduced Medicare Choices Empowerment and Protection Act, seniors could pocket up to $75 for completing advance directives. Directives are written instructions in which people specify what healthcare actions should be taken if they cannot speak for themselves.

“It’s just smart,” says Coburn, a family physician. “This is good medicine for a doctor to know what a patient wants.”

The bill, co-sponsored by Democratic Senator Chris Coons of Delaware, would encourage people on Medicare to register advance directives with the Centers for Medicare and Medicaid Services (CMS). Medicare beneficiaries would receive a one-time payment of $75 for creating an online directive, or $50 for creating one manually in 2015. The payment from CMS would come either as a check or direct deposit.

Inflation would determine payment in subsequent years.

“Here is an incentive to say ‘I want all the care that I can get,’ or perhaps, ‘here is the care that I want,’ and put it down,” says Coburn, who was diagnosed with a prostate cancer recurrence last year. He recently announced his retirement from the Senate effective next January.

Coburn, 66, created his advance directive 20 years ago. He says his care preferences remain the same as those he indicated then: no invasive, life-sustaining interventions. “I have communicated with my family, and I don’t fear death,” Coburn says. “There is a natural end to life.”

The bill would not create a national directive registry. Individuals would indicate in their annual Medicare registration where theirs is maintained. “There is not a role for federal government in keeping documents,” says Coburn. “We want this in private hands.”

If the bill is enacted, however, critics say an advance directive influx could result in widespread administrative confusion.

“Any online database must meet security standards, follow HIPAA regulations and connect to many varied, incompatible medical records systems,” says bioethicist Craig Klugman, Department of Health Sciences Chair at DePaul University.

Klugman says advance directives are ideally completed once people understand the care options that may arise and have discussed scenarios with family members who are likely to be present in a medical crisis or at the end of life.

“It is quite possible to get people to fill out documents and do paperwork,” says Bud Hammes, director of Medical Humanities at Gundersen Health System in La Crosse, Wisconsin. “But it sometimes creates more conflict than it resolves, especially if the paperwork is about checking boxes without much thinking and without discussing it with a family member.”

Most advance directives include options regarding cardiopulmonary resuscitation, artificial nutrition and hydration, intensive care and comfort care.

“Without understanding what goes into the planning process, we are not paying for something that will help,” Hammes says.

Coburn calls the forms “a pain in the butt to do,” a reason he cites for his patient incentive-based proposal.

A measure to reimburse doctors for facilitating discussions with Medicare patients about end-of-life issues was dropped from early versions of the Affordable Care Act after accusations among political opponents that the provision would establish “death panels.” End-of-life counseling is currently a voluntary physician service.

Klugman calls the intent of Coburn’s bill a “noble one,” but he says approaching end-of-life issues requires a multi-factorial approach for effective patient engagement.

“Why aren't we concerned about incentivizing physicians to have these conversations?” Klugman asks. “Providers should be asking their patients these questions at every visit. In market-based medicine, doctors cannot afford to take time to have meaningful end-of-life conversations when that time is a donation of their services.”

Coburn says these dialogues are ones he has always initiated with older patients to ensure autonomy. Patients, he says, are entitled to the care they want and not the care “that a hospital lawyer says they should get.”

Coburn says he hopes fellow lawmakers will view the issue from his perspective as a physician. “I don’t think it’s political at all, and it makes good sense in the practice of medicine.”

A spokesperson from Coburn’s office said the bill has been referred to the Finance Committee. That committee will decide whether or not to send the bill to the Senate for a vote.

In the meantime, people who wish to complete an advance directive - without being paid for it, of course - can look here for a list of sites online where the documents are available: bit.ly/1iod4F2.

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