May 2016


www.hamptonroadsmessenger.com


Study: With New Medicare Benefit, Doctors Look Beyond ‘Death Panels’


The Hampton Roads Messenger 15 • One-quarter of the doctors said


there is no place in their electronic health record indicating if a patient has an advance care plan. For those who do, only about half said they can actually access the plan’s contents.


• Fewer than half of the physicians


said they had the conversation with their own health care providers. But those who had were more apt to engage their patients in the conversation and bill Medicare (20 percent vs. 7 percent who hadn’t).


• Less than one-third said they’ve


had any formal training on talking with patients and their families about EOL care. The percentages were even lower — just one-quarter– among physicians who were over age 50, or who regularly saw fewer ethnically or racially diverse patients (below 25 percent).


BY PAUL KLEYMAN implemented this While 95 percent of doctors


support the new Medicare benefit reimbursing them for discussing end-of-life


(EOL) preferences with


their patients, few have actually used the opportunity. And almost half (46%) report feeling unsure of what to say to their older patients once they’re in the examination room, according to a national poll of physicians.


“There seems to be a huge


disconnect between doctors who want to do the right thing,” said Tony Back, MD, codirector of the Cambia Palliative Care Center, University of Washington, Seattle, and the finding that only 14 percent of them have actually had the conversation


and billed Medicare.


The Cambia Foundation supported the research.


The new study, which Back and


other experts discussed in a national webinar in mid-April, is the first national survey of physicians on their attitudes about EOL care planning since Medicare began the benefit in January.


The survey of 736 primary care


and specialist physicians focused on factors preventing physicians from talking with patients about EOL and advance- care planning?


Ethnic Doctors Unsure The findings exposed many


complicated concerns that researchers will explore in a follow-up study, which will gather doctors in focus groups.


For instance, in the new survey


three-of-four doctors said the Medicare benefit would make them more likely to talk with older patients


But six-in-10 of the ethnic medical practitioners—significantly than


diverse physicians. more


the feeling “These white uncomfortable


conversations with their patients.


conversations, though


not easy, benefit from taking into account the patient and physician’s knowledge, attitudes and beliefs about end-of-life care options,” said Sandra R. Hernandez, MD, a primary care physician and president and CEO of the California Health Care Foundation, a study sponsor.


Medicare reimbursement for the voluntary EOL


conversations was


proposed as part of the Affordable Care Act, but derailed when 2008 vice-pres- idential candidate Sarah Palin called it “death panels.”


about


advance-care planning. That figure was higher (85 percent) among racially or ethnically


doctors—admitted having EOL seriously-ill


In fact, the benefit, finally year


through the


federal Centers for Medicare and Medicaid Services, allows patients to learn about their options and state their preferences in multiple talks with their doctor long-before they face a medical crisis.


The idea has been supported by


80 percent of the public, according to the Kaiser Family Foundation, as well as being endorsed by the American Medical Association and other medical groups.


Care Wishes The Cambia center’s Tony Back,


explained, “You may want to have all the medical care that is reasonable, and when it’s your time — pass away quietly in your own bed. If you don’t have this conversation and your doctor doesn’t know what you want and your family member doesn’t feel sure about what to do, you can easily end up in the intensive care unit with a catheter in your bladder, a tube down your throat, a tube down your nose, and IV in your neck, IVs in your arms — in a bright noisy place. That will be the last moments you have on this earth.”


Terry Fulmer, PhD, a nurse and


president of the John A. Hartford Foundation, also a survey sponsor, stated, “Too many people at the end of life receive care that is completely at odds with their personal wishes.” She called Medicare’s new benefit “a promising first step in ensuring that more people remain in control of their health care experience to the very last day of their lives.”


CHCF Program Officer Kate


O’Malley, a certified palliative and hospice nurse, observed, “The nice thing about the Medicare benefit is that it doesn’t mean you can only use it one time.”


She noted wellness that


included two new billing codes: One reimburses $86 for


the examination,


conversation, such as during a senior’s annual


Medicare initial and


another paying doctors slightly less for follow-up talks. ”If you have a change in condition, you can check back in again. So it’s a continuous reimbursement said.


strategy,” O’Malley Besides the insurance coverage,


though, complex barriers persist. The survey also included such key findings as:


• Only three in 10 respondents report their practice or health care system has a formal


system for


assessing patients’ end-of-life wishes and goals of care.


Prince would happen.


FROM PAGE 3


At the same time, he implored me and my friend Paula Madison, who I had introduced to him, to make a documentary of the groundbreaking moment that was about to happen. Paula


happened to own a cable


channel, so even though we were days away from the opening of the shows at the Forum, we did it. We transformed the decaying space into a film studio, interviewed everybody from George Lopez to Chaka Khan, edited, and aired


a special on Paula’s Africa


Channel, all within a week. And we were nominated for an NAACP Image Award. We did the impossible because Prince did not believe in impossible. He imbibed the heartbeat of possibility in the now.


memories


I have a thousand amazing of this amazing


man.


Perhaps the most tender is when he took the time out from directing a rehearsal in Los Angeles to talk to my daughter, who was then about 7. She had been learning one of his songs in school, and I had told him. He rode his bike over to see her just before a rehearsal and said, “I hear you are learning one of my songs in school.” With eyes wide open, she quietly said,


“Yes, ‘Starfish and Coffee.’” He countered, “Well, I will change the playlist tonight and add that song. Will you perform it with me?” to which her eyes grew to saucer-size and


she stammered, “I haven’t


memorized all the words yet.” Prince said, “I don’t want you to sing it, I want you to play. Do you play the piano?” She said, “I am learning.” Prince: “Every princess must learn to play the piano,” and then he looked to my husband and me and added, “Every home should have a piano. It brings good energy and helps to grow the plants.”


While we do not have a piano today (my daughter has chosen to play the cello), I will never forget his generosity. Prince gave,


endlessly,


usually privately with no need or desire for acknowledgment. As much as he was a wildly sexual being, he was also a consummate gentleman and visionary.


I loved the awake-all-night year


that I spent traveling the country with him. I will never forget the gut-level conviction he had that we are all expressions of God and that we all should step up and live our God selves. And now that he is gone, I remember the haunting lines of a song he sang beautifully though he did not write, “What if God was one of us?”


at Odds With Patients’ ethnic


of any ethnicity diverse


The researchers found that both doctors and the physicians who treat


more groups of patients to be


more uncomfortable having the EOL conversations. However, more of them also admitted feeling unsure of how to approach the discussion in a culturally appropriate way than white medical practitioners did.


More Complex Than Language


Interpretation The multicultural issues beyond


the challenges of medical-language interpretation,


said the University


of Washington’s Tony Back, are complex and require a more advanced communication level. Many in Navajo culture, for instance, believe talking about death means that death happens, he noted.


Communication Patients: Empathy University “These are


Back, also the author of Mastering with Seriously Ill Honesty with


Balancing


and Hope (Cambridge Press, 2009), continued, skills


like how do you


show empathy to an Asian patient who doesn’t express a lot of emotions, for example? How do you summarize medical information for a person who


has low medical literacy? How to you talk about end-of-life decisions with someone who’s never discussed something like that.”


Speculating about why more


ethnic doctors feel uncertain about what to say to their ethnic patients and their family member, Lisa Folberg, president and CEO of the California Medical


Association Foundation


(CMA Foundation) observed, “I think they’re just more aware.”


She went on, “They realize more than older white physicians that there are a lot of nuances. So it’s almost like the groups that feel more comfortable don’t know what they don’t know. For the racially and ethnically diverse physicians, they know there’s a lot they don’t know about how to talk to patients in a culturally appropriate way.”


includes


The CMA Foundation, which the


Network of Ethnic


Physician Organizations (NEPO), is now recruiting MDs for the in-depth focus-group study to understand the initial survey results better. NEPO includes 50 ethnic medical societies representing California.


20,000 doctors said, “We to in


In this second study, Folberg hope


develop some


lessons learned and be able to share those to physicians around California and elsewhere.”


Folberg, who noted that health care the


CMA Foundation is a nonpartisan organization


California Medical Association, said that


sensitively into


conversations. “It’s really important


separate from the providers within


another ethnic group or within the same ethnicity as a patient need to tread


end-of-life for


physicians of color and the whole care team to be engaged in that process, because they’re really a trusted messenger for those communities,” Folberg said.


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