Medicare pushes end-of-life discussions in hospitals

• Only about a third of U.S. adults have documented their end-of-life care wishes. More consultations could reduce costly life-extending treatments that patients don't really want.

Driving the news: The administration is proposing that hospitals begin reporting adult patients' preferences for end-of-life care in electronic health records starting in 2028.

• The records would be added to a menu of quality metrics that could affect Medicare reimbursements starting in 2030. Hospitals can choose from the menu options but have to report a set number or see their payments cut.
• The requirement covers "do not resuscitate" orders, durable power of attorney for health care or requests for life-sustaining care. Proof of a discussion about such options would also count for a positive score.

The Centers for Medicare and Medicaid Services says the quality measure would prod providers and patients to confront sensitive decisions about medical intervention.

• "[T]he goal of this measure is to establish advance care planning as a normalized, routine part of care regardless of health status and age," CMS wrote in its proposal.
• Medicare has paid clinicians for having advance care planning conversations with patients since 2016, but only about 5% billed for them in 2021, per CMS.

The intrigue: Advocates have discussed ways to increase advance care planning for years. But they say CMS administrator Mehmet Oz was instrumental in pushing the proposal forward.

• "When the administrator of Medicare says this is an important issue, things that have been on the back burner suddenly move to the front burner," said Ron Kline, who recently retired as chief medical officer of Medicare's Quality Measurement and Value-Based Incentives Group.
• CMS didn't respond to a request for comment.

What they're saying: The proposal is an important step for patients and their families, said Marian Grant, a nurse and the senior regulatory advisor for the Coalition to Transform Advanced Care.

• "If you're in a hospital, something could happen, maybe you wouldn't be able to speak for yourself," she said.
• "We need to know what it is you want, or who should your decision-maker be."

Between the lines: The focus on eliminating unnecessary care comes as Medicare is being squeezed by an aging population and rising demand for services and expensive drugs.

• Medicare recipients who make their care preferences known save the federal government more than $10,000 in their last year of life compared with those who don't, analysis the LeadingAge LTSS Center, a research institution.
• The government doesn't take a position on what end-of-life care goals should look like — it just wants to ensure that patients have a say, Kline said.

Yes, but: Some providers warn that typical advance care planning doesn't actually prepare patients to navigate gray areas, or how care preferences change over time.

• A 2024 study of nearly 12 million Medicare beneficiaries found that increasing advance care planning discussions didn't necessarily change hospitals' treatment plans or patient outcomes.

Hospitals are wary of the measure, too. Trade groups including the American Hospital Association and the Catholic Health Association say advance care planning is important, but they're concerned the measure hasn't been thoroughly vetted.

• "We strongly believe that [quality measures] should not detract from what is most important for the patient — time spent with the patient providing quality health care," the Catholic hospital group wrote to Medicare administrators, citing concerns about burdensome regulations.

What's ahead: Medicare is expected to make a final decision on whether to add the measure later this summer.