October 23, 2014

Death Panels Part II: How Advance Care Planning and Palliative Care Relate to Current Health Reform Efforts

In my previous post, I spent some time clarifying how “advance care planning” is in no way, shape or form the same as a “death panel,” and how palliative care does not equate to any "rationing of care." Rather, both these health care interventions are patient-centered and improve the value of the health care experience for severely, chronically, and terminally ill patients and their families.

As Congress resumes its work and health reform continues to dominate talks on Capitol Hill, I'd like to put these in context given the status of health reform today.

The philosophy behind advance care planning fits nicely with the promotion of an Independent Payment Advisory Board tasked to make recommendations to Congress on slowing future Medicare cost growth. Similarly to advance care planning, where potential treatment options and often difficult decisions are discussed prior to a health crisis, the Independent Payment Advisory Board (IPAB) is being asked to evaluate the tough choices facing the longevity and fiscal health of the Medicare program in advance of a federal budget crisis. The Advisory Board would be made up of health care experts, people who entered their professions because they care most about patients and preserving those programs that serve their patients. While these experts will face very difficult decisions because the revenue-to-outlays imbalance for the Medicare program grows greatly over time, they are not tasked with hastening seniors’ deaths. Rather this group of health experts is asked to make recommendations about tough choices surrounding the structure of the program to ensure its viability far into the future. This is an increasingly important task since health care costs keep rising and employer-based retiree benefits are less certain than ever.

Therefore, empowering an independent body to make recommendations to improve Medicare certainly does not equate to a death panel but rather a life-line that will ensure Medicare exists and provides health care benefits far into the future for seniors. 

Two other aspects included in health reform bills -- medical homes and accountable care organizations -- also share similarities with the philosophies and implementation of advance care planning and palliation. A medical home is defined here as an approach to providing comprehensive primary care that facilitates partnerships between individual patients (and families) and their personal physicians. An accountable care organization (ACO) is defined here as an integrated health system that relies on a network of primary care physicians, one or more hospitals, and subspecialists to provide care to a defined patient population.

They, too, are patient-centered and involve providers taking the steps necessary to meet the comprehensive needs of the patient -- even if it means providing less care rather than more (and causing them to lose income under a traditional fee-for-service payment structure). Under models for medical home and accountable care, not only should “value” be added to the patient’s health care experience, but provider payments are aligned with quality and system efficiencies which, over time, can improve Medicare’s long-term sustainability. To that end, The Concord Coalition supports Medicare payment reform whereby practitioners are paid for quality outcomes rather than on a fee-for-service basis with its often perverse incentives to “do more” rather than “do what works” and is in the best interest of the patient.

In conclusion, health reform being discussed in Washington includes provisions that could improve the "patient-centeredness" of America's health delivery system in a fiscally responsible manner. I hope our elected officials recognize the value of keeping in the final bill The IPAB as well as an emphasis on promoting medical homes and accountable care organizations. These programs provide some of the best options yet for improving Medicare and the entire health care system in a way that focuses on the patient as well as the bottom line.