As the sole physician in my large and far-flung family, I am accustomed to receiving phone calls and emails from relatives seeking medical advice or simple confirmation that they and their doctor are making the right health care decisions. This is typical, and a reality to which I know most medical providers can relate. However, the strangest communication of this sort came in the form of an email, from my mother.
Subject: Not urgent
Message: Does a DNR cover everything?
My parents are not regular email users, so even though this message was labeled as Not urgent, my curiosity about what prompted it was certainly piqued. Despite being in the midst of a booked all-day clinic, the email clearly necessitated a telephone call. My mother had recently moved to Florida and established care with a new primary care doctor. As she was checking out of the office, the nurse—or maybe the receptionist—gave her an advance directive for healthcare and told her that the doctor likes everyone to have the form. There was no conversation between the physician and the patient: My mother.
The possibility that there may one day be value recognized in end-of-life counseling has been resurrected this summer by Senators Mark R. Warner and Johnny Isakson. Their new bill was introduced in August, and goes beyond the previous, similar bill introduced in March by Rep Earl Blumenauer. Both bills, currently in committees, are intended to reimburse medical professionals for the time invested in these end-of-life conversations, develop a public information campaign, and develop quality metrics to measure the effectiveness in delivering the desired medical care.
This process will encourage patients to be informed and specify their end-of-life preferences, whether they be the DNR that proved perplexing to my mother, or a do “everything medically possible” order. Republican co-sponsors are certainly a boon to the bill’s future. Rep. Blumenauer has vowed to talk to every member of Congress to build support, and it is my hope—along with that of so many of my colleagues nationwide—that he proves successful.
The need for a bill is revealed in a recent study in the Journal of the American Medical Association. As background, physician payment is currently based on a value assigned, by Medicare and Medicaid Services, to the physician-specific work. The hourly revenue generated by a physician providing a cognitive service, one that involves thinking, reasoning and judgment without a procedure, is $87. That same physician—if conducting a procedure such as a colonoscopy or a cataract extraction—will make more than $300 per hour for the physician time associated with that service. This discrepancy results in fewer physicians entering cognitive fields and less time allotted per patient, at a time when more people are living longer with chronic illness.
The study proves that medical conversation, the intimate kind that often only occurs within an examination room in the presence of a physician, is not valued highly by the American health care system. Medicare’s reimbursement for procedural care at a rate three-to-five times higher than that of cognitive care is a daunting reality that leads many of my fellow physicians to be pessimistic that any compensation for end of life dialogue will ever be valued. Among other things, the new legislation will assign a code and value to the complex discussion of end of life planning. Some may argue that this cannot be compared to the complexity of a procedure such as a colonoscopy or a cataract extraction. However, having an advance care planning discussion that results in a documented care plan to reflect informed choices is a skill that must be taught, learned and practiced just as intensively as any medical procedure. A poorly conducted end of life discussion will leave a scar deeper than any surgeon’s knife.