IDEAS AND OPINIONS
IMPROVING PATIENT CARE
Can the United States Buy Better Advance Care Planning? Scott D. Halpern, MD, PhD, and Ezekiel J. Emanuel, MD, PhD
S
ince the early 1980s, the delivery of care near the end of life in the United States has changed dramatically—and improved— often without much notice. The rights of persons to refuse all types of medical interventions are well-established and no longer litigated. Pain is now the fifth vital sign. Specialized palliative care consultative services are available in most U.S. hospitals (1). Increasing numbers of persons in the United States die while receiving hospice care, including 60% of those who have died of cancer (2). And new initiatives are increasingly prompting clinicians and patients to engage in advance care planning, such as completing written advance directives. Yet, even with these changes, much has nonetheless stayed the same. Despite nearly 30 years of effort to get persons in the United States to complete advance directives, a recent trial of patients most likely to benefit from them—those with unequivocally terminal illnesses and limited life expectancies—showed that only half had completed one (3). Many persons in the United States still spend time in the last 6 months of life (and often die) in intensive care units (2). Too many patients in the last days of life receive aggressive treatments, including surgery (4), and too few have adequate symptom control. And more than 25% of Medicare dollars are still allocated to care for patients in their final year of life—a proportion that has not changed in decades (5). In light of this pernicious status quo, the call from the Institute of Medicine (IOM) Committee on Approaching Death for sweeping overhauls in the delivery of end-of-life care is greatly needed. However, whereas change is urgent, making the right changes—and motivating those changes with the right messages—may be even more essential. Physicians, hospitals, and health care systems have finite capacities to implement substantial changes in care and policy. And, as evidenced by the charges of death panels, euthanasia, rationing, and worse that derailed previous efforts to improve end-of-life care, the few political chips that might be played in this arena must be played wisely. Consequently, one of the Committee's central recommendations, to reimburse physicians for engaging patients in advance care planning, merits careful consideration. Although this recommendation has some bipartisan support, including the Personalize Your Care Act of 2013 (6), it poses at least 4 potential concerns.
See also: Related articles . . . . . . . . . . . . . . . 175, 226, 228, 230 Celebrating the ACP Centennial: From the Annals Archive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 This article was published online first at www.annals.org on 9 December 2014. 224 © 2015 American College of Physicians
First, motivating advance care planning with physician-directed incentives may be putting the cart before the horse. Despite tremendous face validity to the concept, almost nothing is known about how best to engender discussions of true goals, the types of potential future health states that patients should contemplate, or how patients should document their treatment preferences if they entered such health states. Without first determining what specific elements of conversations and written directives best promote the interests of patients and their family members, there is little reason to expect that nonspecific incentives to “have a discussion” or “complete a form” will do much good. Second, there may be nothing harder in medical care—cognitively, technically, or emotionally—than talking to patients, especially younger ones, about dying and advance care planning. Bringing up the topic, guiding the conversation to stay focused on the issues and clinical options, and ultimately reaching decisions are not skills that most clinicians have naturally. Rather, they require training, cultivation, and practice. If the major barrier to engaging patients about end-oflife care is physicians' perceived lack of capacity to engage in these conversations, money is unlikely to be the right catalyst. Several programs are already available to train clinicians— both physicians and nurses—to initiate and lead these discussions (7, 8). It would be wise to invest in optimizing and disseminating such training before incentivizing low-quality discussions by unskilled providers. Third, various modifications of systems may facilitate end-of-life discussions without using incentives. For example, an oncology group in southeastern Pennsylvania has a reminder built into their electronic health record to prompt physicians to have and document end-of-life discussions with patients who develop metastatic solid cancer or have a low performance status. Anecdotally, this and other system interventions have been associated with increased hospice referral and length of stay. Further, although it is premature to specifically reimburse physicians for time spent in advance care planning, the time to change physician reimbursement more generally has long passed. Physician payments should be geared more toward time spent thinking about and interacting with patients and families than doing things to them. A model for such reimbursement is already well-established: Critical care physicians have long been paid on the basis of the number of minutes that they devote each day to meeting patients' critical care needs. Such reimbursement does not specifically incentivize palliative care provision or end-of-life conversations. But by reimbursing conversations about goals of care on a level playing field with the titration of
IDEAS AND OPINIONS
Can the United States Buy Better Advance Care Planning?
vasoactive medications and ventilator settings, critical care physicians do not face the same opportunity costs that other physicians do when engaging patients and families in frank discussions. And if money is to be used to more directly incentivize completion of advance directives and conversations about goals of care, we need to determine whether incentivizing physicians rather than patients themselves, as the Medicare Choices Empowerment and Protection Act advocates (9), would be better—and more publicly palatable. Finally, changes to the overall clinical infrastructure need to be put in place to ensure that, when patients do make their wishes known, they are truly actionable. Often, seemingly well-laid plans are not followed because the health system is designed to make hospitalization the easiest option. No matter how resolute one's desires to be cared for at home, in the event of a sudden clinical deterioration, if families or clinicians are uncertain of the ability to mobilize compassionate and coordinated home-based care, then hospitalization may happen by default. Will these changes—training physicians and nurses to engage in end-of-life discussions and revising systems to promote such discussions and infrastructures to facilitate palliative, outpatient-based treatment pathways—actually save money? We simply do not know. Observational studies suggest that palliative care consultations (10) are associated with reduced cost, but these relationships are at least as likely to be due to differences in patients as they are to be causal. Regardless, motivating change in end-of-life care by its potential for cost savings, as incentives may subconsciously imply, risks focusing too much of the attention on the high (but potentially not too high) costs of end-of-life care in the United States and not enough on the many opportunities to improve its quality. From the Leonard Davis Institute of Health Economics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania. Grant Support: Dr. Halpern was supported by a Greenwall
Foundation Faculty Scholar Award in Bioethics.
www.annals.org
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje /ConflictOfInterestForms.do?msNum=M14-2476. Requests for Single Reprints: Scott D. Halpern, MD, PhD, University of Pennsylvania, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, shalpern@exchange .upenn.edu.
Current author addresses and author contributions are available at www.annals.org. Ann Intern Med. 2015;162:224-225. doi:10.7326/M14-2476
References 1. American Hospital Association. American Hospital Association Annual Hospital Surveys for FY 2000 to 2010. Accessed at www.hpoe .org/resources/hpoehretaha-guides/1148 on 19 November 2014. 2. Teno JM, Gozalo PL, Bynum JP, Leland NE, Miller SC, Morden NE, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309:470-7. [PMID: 23385273] doi:10.1001/jama .2012.207624 3. Halpern SD, Loewenstein G, Volpp KG, Cooney E, Vranas K, Quill CM, et al. Default options in advance directives influence how patients set goals for end-of-life care. Health Aff (Millwood). 2013;32: 408-17. [PMID: 23381535] doi:10.1377/hlthaff.2012.0895 4. Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet. 2011;378:1408-13. [PMID: 21982520] doi:10.1016/S0140-6736(11)61268-3 5. Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010;45:565-76. [PMID: 20148984] doi:10.1111/j.1475-6773.2010.01082.x 6. Personalize Your Care Act of 2013, H.R. 1173, 113th Cong. (1st Sess. 2013). 7. Back AL, Arnold RM, Baile WF, Fryer-Edwards KA, Alexander SC, Barley GE, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167:453-60. [PMID: 17353492] 8. Quest T, Emanuel L, Gisondi M, Engel K, Osgood K. Impact of the education in palliative and end-of-life care project on emergency medicine education and practice. J Pain Symptom Manage. 2010; 39:334-5. 9. Medicare Choices Empowerment and Protection Act, S. 2240, 113th Cong. (2nd Sess. 2014). 10. May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17:1054-63. [PMID: 24984168] doi:10.1089/jpm.2013.0594
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015 225
IMPROVING PATIENT CARE Current Author Addresses: Dr. Halpern: University of Pennsyl-
Author Contributions: Conception and design: S.D. Halpern,
vania, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021. Dr. Emanuel: Department of Medical Ethics and Health Policy, University of Pennsylvania, 3401 Market Street, Suite 320, Philadelphia, PA 19104.
E.J. Emanuel. Drafting of the article: S.D. Halpern, E.J. Emanuel. Critical revision of the article for important intellectual content: S.D. Halpern, E.J. Emanuel. Final approval of the article: S.D. Halpern, E.J. Emanuel. Administrative, technical, or logistic support: S.D. Halpern. Collection and assembly of data: E.J. Emanuel.
www.annals.org
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015
Copyright © American College of Physicians 2015.
IMPROVING PATIENT CARE
Can the United States Buy Better Advance Care Planning? Scott D. Halpern, MD, PhD, and Ezekiel J. Emanuel, MD, PhD
S
ince the early 1980s, the delivery of care near the end of life in the United States has changed dramatically—and improved— often without much notice. The rights of persons to refuse all types of medical interventions are well-established and no longer litigated. Pain is now the fifth vital sign. Specialized palliative care consultative services are available in most U.S. hospitals (1). Increasing numbers of persons in the United States die while receiving hospice care, including 60% of those who have died of cancer (2). And new initiatives are increasingly prompting clinicians and patients to engage in advance care planning, such as completing written advance directives. Yet, even with these changes, much has nonetheless stayed the same. Despite nearly 30 years of effort to get persons in the United States to complete advance directives, a recent trial of patients most likely to benefit from them—those with unequivocally terminal illnesses and limited life expectancies—showed that only half had completed one (3). Many persons in the United States still spend time in the last 6 months of life (and often die) in intensive care units (2). Too many patients in the last days of life receive aggressive treatments, including surgery (4), and too few have adequate symptom control. And more than 25% of Medicare dollars are still allocated to care for patients in their final year of life—a proportion that has not changed in decades (5). In light of this pernicious status quo, the call from the Institute of Medicine (IOM) Committee on Approaching Death for sweeping overhauls in the delivery of end-of-life care is greatly needed. However, whereas change is urgent, making the right changes—and motivating those changes with the right messages—may be even more essential. Physicians, hospitals, and health care systems have finite capacities to implement substantial changes in care and policy. And, as evidenced by the charges of death panels, euthanasia, rationing, and worse that derailed previous efforts to improve end-of-life care, the few political chips that might be played in this arena must be played wisely. Consequently, one of the Committee's central recommendations, to reimburse physicians for engaging patients in advance care planning, merits careful consideration. Although this recommendation has some bipartisan support, including the Personalize Your Care Act of 2013 (6), it poses at least 4 potential concerns.
See also: Related articles . . . . . . . . . . . . . . . 175, 226, 228, 230 Celebrating the ACP Centennial: From the Annals Archive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 This article was published online first at www.annals.org on 9 December 2014. 224 © 2015 American College of Physicians
First, motivating advance care planning with physician-directed incentives may be putting the cart before the horse. Despite tremendous face validity to the concept, almost nothing is known about how best to engender discussions of true goals, the types of potential future health states that patients should contemplate, or how patients should document their treatment preferences if they entered such health states. Without first determining what specific elements of conversations and written directives best promote the interests of patients and their family members, there is little reason to expect that nonspecific incentives to “have a discussion” or “complete a form” will do much good. Second, there may be nothing harder in medical care—cognitively, technically, or emotionally—than talking to patients, especially younger ones, about dying and advance care planning. Bringing up the topic, guiding the conversation to stay focused on the issues and clinical options, and ultimately reaching decisions are not skills that most clinicians have naturally. Rather, they require training, cultivation, and practice. If the major barrier to engaging patients about end-oflife care is physicians' perceived lack of capacity to engage in these conversations, money is unlikely to be the right catalyst. Several programs are already available to train clinicians— both physicians and nurses—to initiate and lead these discussions (7, 8). It would be wise to invest in optimizing and disseminating such training before incentivizing low-quality discussions by unskilled providers. Third, various modifications of systems may facilitate end-of-life discussions without using incentives. For example, an oncology group in southeastern Pennsylvania has a reminder built into their electronic health record to prompt physicians to have and document end-of-life discussions with patients who develop metastatic solid cancer or have a low performance status. Anecdotally, this and other system interventions have been associated with increased hospice referral and length of stay. Further, although it is premature to specifically reimburse physicians for time spent in advance care planning, the time to change physician reimbursement more generally has long passed. Physician payments should be geared more toward time spent thinking about and interacting with patients and families than doing things to them. A model for such reimbursement is already well-established: Critical care physicians have long been paid on the basis of the number of minutes that they devote each day to meeting patients' critical care needs. Such reimbursement does not specifically incentivize palliative care provision or end-of-life conversations. But by reimbursing conversations about goals of care on a level playing field with the titration of
IDEAS AND OPINIONS
Can the United States Buy Better Advance Care Planning?
vasoactive medications and ventilator settings, critical care physicians do not face the same opportunity costs that other physicians do when engaging patients and families in frank discussions. And if money is to be used to more directly incentivize completion of advance directives and conversations about goals of care, we need to determine whether incentivizing physicians rather than patients themselves, as the Medicare Choices Empowerment and Protection Act advocates (9), would be better—and more publicly palatable. Finally, changes to the overall clinical infrastructure need to be put in place to ensure that, when patients do make their wishes known, they are truly actionable. Often, seemingly well-laid plans are not followed because the health system is designed to make hospitalization the easiest option. No matter how resolute one's desires to be cared for at home, in the event of a sudden clinical deterioration, if families or clinicians are uncertain of the ability to mobilize compassionate and coordinated home-based care, then hospitalization may happen by default. Will these changes—training physicians and nurses to engage in end-of-life discussions and revising systems to promote such discussions and infrastructures to facilitate palliative, outpatient-based treatment pathways—actually save money? We simply do not know. Observational studies suggest that palliative care consultations (10) are associated with reduced cost, but these relationships are at least as likely to be due to differences in patients as they are to be causal. Regardless, motivating change in end-of-life care by its potential for cost savings, as incentives may subconsciously imply, risks focusing too much of the attention on the high (but potentially not too high) costs of end-of-life care in the United States and not enough on the many opportunities to improve its quality. From the Leonard Davis Institute of Health Economics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania. Grant Support: Dr. Halpern was supported by a Greenwall
Foundation Faculty Scholar Award in Bioethics.
www.annals.org
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje /ConflictOfInterestForms.do?msNum=M14-2476. Requests for Single Reprints: Scott D. Halpern, MD, PhD, University of Pennsylvania, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021; e-mail, shalpern@exchange .upenn.edu.
Current author addresses and author contributions are available at www.annals.org. Ann Intern Med. 2015;162:224-225. doi:10.7326/M14-2476
References 1. American Hospital Association. American Hospital Association Annual Hospital Surveys for FY 2000 to 2010. Accessed at www.hpoe .org/resources/hpoehretaha-guides/1148 on 19 November 2014. 2. Teno JM, Gozalo PL, Bynum JP, Leland NE, Miller SC, Morden NE, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309:470-7. [PMID: 23385273] doi:10.1001/jama .2012.207624 3. Halpern SD, Loewenstein G, Volpp KG, Cooney E, Vranas K, Quill CM, et al. Default options in advance directives influence how patients set goals for end-of-life care. Health Aff (Millwood). 2013;32: 408-17. [PMID: 23381535] doi:10.1377/hlthaff.2012.0895 4. Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet. 2011;378:1408-13. [PMID: 21982520] doi:10.1016/S0140-6736(11)61268-3 5. Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010;45:565-76. [PMID: 20148984] doi:10.1111/j.1475-6773.2010.01082.x 6. Personalize Your Care Act of 2013, H.R. 1173, 113th Cong. (1st Sess. 2013). 7. Back AL, Arnold RM, Baile WF, Fryer-Edwards KA, Alexander SC, Barley GE, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med. 2007;167:453-60. [PMID: 17353492] 8. Quest T, Emanuel L, Gisondi M, Engel K, Osgood K. Impact of the education in palliative and end-of-life care project on emergency medicine education and practice. J Pain Symptom Manage. 2010; 39:334-5. 9. Medicare Choices Empowerment and Protection Act, S. 2240, 113th Cong. (2nd Sess. 2014). 10. May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17:1054-63. [PMID: 24984168] doi:10.1089/jpm.2013.0594
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015 225
IMPROVING PATIENT CARE Current Author Addresses: Dr. Halpern: University of Pennsyl-
Author Contributions: Conception and design: S.D. Halpern,
vania, 719 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021. Dr. Emanuel: Department of Medical Ethics and Health Policy, University of Pennsylvania, 3401 Market Street, Suite 320, Philadelphia, PA 19104.
E.J. Emanuel. Drafting of the article: S.D. Halpern, E.J. Emanuel. Critical revision of the article for important intellectual content: S.D. Halpern, E.J. Emanuel. Final approval of the article: S.D. Halpern, E.J. Emanuel. Administrative, technical, or logistic support: S.D. Halpern. Collection and assembly of data: E.J. Emanuel.
www.annals.org
Annals of Internal Medicine • Vol. 162 No. 3 • 3 February 2015
Copyright © American College of Physicians 2015.
