In an effort to improve end-of-life medical care, U.S. Rep. Earl Blumenauer has introduced legislation that would require Medicare to reimburse physicians for discussing end-of-life choices with patients.
The Oregon Democrat's so-called Life Sustaining Treatment Act of 2009 marks an important step in broadening the conversation between doctors and patients, says Steve Hopcraft, spokesman for Denver-based Compassion Choices—a nonprofit that advocates improved care at the end of life.
"Doctors avoid the conversation. Who doesn't? There is a conspiracy of factors not to talk about [end-of-life care]," Hopcraft says. "Having [the discussions] would allow more at-home death or hospice care and less invasive procedures."
Blumenauer's HR 1898, which is now part of a larger healthcare reform bill, would require Medicare to cover one voluntary consultation every five years, but would not require that consultation or the establishment of a living will.
Physicians now receive no financial incentive to have these talks with patients. Blumenauer says the cost of his bill remains uncertain since health care has never paid somebody to have that conversation with patients.
"If people know what their choices are, and think about it in advance, they end up less likely to do expensive treatment they don't want," Blumenauer says. "I think it will end up being a wash."
Some studies suggest there could be actual savings. A March 2009 study in the Archives of Internal Medicine suggested savings of more than $76 million a year if half the people who die from cancer annually had end-of-life conversations with their physicians.
If Blumenauer's proposal passes, it could open up similar end-of-life consultations to privately insured patients, says Angela Hult, spokeswoman for Regence Blue Cross Blue Shield.
The congressman's idea has caught heat from Rush Limbaugh. The radio talk show host blasted the idea on his July 21 show as "an invasion of the right to privacy" and labeled it as "mandatory counseling for all seniors at a minimum of every five years, more often if the seasoned citizen is sick or in a nursing home."
And the Catholic Medical Association also opposes the bill. "[CMA] cannot support Rep. Blumenauer's bill until it is clear that such consultations would be voluntary and that other safeguards are in place to protect the elderly against pressure to forgo legitimate medical treatment and care," said John Brehany, executive director and ethicist of the medical group.
Blumenauer says opponents are misrepresenting the proposal.
"This bill simply extends Medicare so it covers a voluntary conversation between a patient and his or her doctor," Blumenauer says.
The push to create federal incentives to discuss end-of-life care percolates from states like Oregon that have endorsed the Physician Order for Life-Sustaining Treatment system, which was largely developed at Oregon Health Science University.
The system has patients and families discuss their end-of-life wishes prior to an emergency and file them in a more accessible registry than a privately held living will.
Physician-assisted dying would not be part of the conversation except for states that already have some form of that provision included in their state laws.
The American Medical Association opposed those state laws in Oregon and Washington. But AMA spokeswoman Katherine Hatwell says Blumenauer's bill is consistent with AMA policy because it echoes the group's support of advance-care planning decisions with formal documents.
The Oregon Medical Association says it also supports this bill and any bill that works to recognize patients' wishes. Betsy Boyd-Flynn, the OMA's deputy executive director, says such doctor-patient discussions would save money and unwanted procedures.
The American Academy of Hospice and Palliative Medicine estimates chronically and seriously ill patients constitute 5 to 10 percent of patients yet account for more than 50 percent of healthcare costs. And more than 25 percent of Medicare costs are incurred in the last year of life, the academy reports.