The country’s system for handling end-of-life care is largely broken and should be overhauled at almost every level, a national panel concluded in a report released Wednesday.
The 21-member nonpartisan committee, appointed by the Institute of Medicine, the independent research arm of the National Academy of Sciences, calls for sweeping change.
“The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” said David M. Walker, a Republican and a former U.S. comptroller general, who was a co-chairman of the panel. “The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want and is also more costly.”
Many of the recommendations could be accomplished without legislation. For example, the panel urged insurers to reimburse health care providers for conversations with patients on advance care planning. Medicare, which covers 50 million Americans and whose members account for about 80 percent of deaths each year, is considering doing just that, prompted by a recent request from the American Medical Association for such coverage.
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Some private insurers are already covering such conversations, and many more would if Medicare were to approve the association’s request.
But some recommendations, like changing the reimbursement structure so that Medicare would pay for home health services instead of emphasizing hospital care, so Medicaid would have better coverage of long-term care for the frail elderly, would require congressional action.
“We know that there may be a need for new legislation to be introduced to accomplish that, and we recognize that that’s harder to accomplish in a politically charged environment,” said Philip A. Pizzo, a former dean of the Stanford University School of Medicine and the committee’s other co-chairman.
The panel, which included doctors, nurses, insurers and experts on aging, says Medicare and other insurers should create financial incentives for health care providers to have continuing conversations with patients on advance care planning, possibly starting as early as major teenage milestones like getting a driver’s license or going to college.
It calls for a “major reorientation and restructuring of Medicare, Medicaid and other health care delivery programs” and the elimination of “perverse financial incentives” that encourage expensive hospital procedures while growing numbers of very sick and very old patients want low-tech services like home health care and pain management.
And it says that medical schools and groups that accredit and regulate health providers should greatly increase training in palliative care and set standards so that more clinicians know how to compassionately and effectively treat patients who want to be made comfortable but avoid extensive medical procedures.
The 507-page report, “Dying in America,” says its recommendations would improve the quality of care and better satisfy more patients and families. It also says the changes would produce significant cost savings that would help make health care more affordable.
“If you meet their needs, treat their pain, treat their depression, get them some help in the house, your costs plummet,” said Diane E. Meier, a committee member and the director of the Center to Advance Palliative Care.
The report’s linkage of end-of-life choices to economic savings is likely to fuel claims by critics of advance care planning who charge that the medical establishment and insurers will subtly pressure people to reject life-sustaining treatment in order to save money.
Burke Balch, the director of the National Right to Life Committee’s Powell Center for Medical Ethics, said in a statement, “The report’s emphasis on cost-slashing will intensify, rather than calm, the well-founded fears of older people and those with disabilities that the renewed push for government funding and promotion of advance care planning is less about discovering and applying their own wishes than about pushing them to accept premature deaths.”
The report is the culmination of two years of research and hearings by the committee. The $1.5 million cost of the work was financed by an anonymous donor who had no control over who served on the committee or over the report itself. The donor recently approved additional funding for a yearlong public education campaign about the report.