The DNR Code
You get what you pay for.
Medicare pays for procedures, so by FSM, procedures are what you're going to get. If the American people decide that futile care is indeed futile -- and that something needs to be done about it -- I have a proposal:
Medicare should pay for DNR orders.
Recognizing the sensitive, difficult and time-consuming nature of the effort required by a physician to discuss end-of-life issues with patients and families, Medicare (and by extension, all other insurers) should create and pay for a procedure code for obtaining a DNR order. This payment should be significant; I'd suggest on the order of at least a Level 4 office visit ("25 minutes face to face time") given the time usually needed for these conversations. Not bundled into a hospital or office visit for other problems or discussions, but a separate, identifiable service that culminates in a DNR order being entered into the patient's medical record. To the extent that a DNR limits futile care, this code should easily pay for itself many times over.
This code should not be limited to use by the primary care provider. If Fat Doctor is the one who takes the time to talk about these issues with the family, she should be paid for it -- above and beyond the DRG hospital payment. (I'm ok with limiting it to once per hospitalization, but not once per patient; people do change their minds.) Same for the ER docs. Would the financial incentives be worth it for the surgeons and subspecialists to take time away from their lucrative procedures? Probably not, though I have no doubt they'd try to claim the payment one way or another. Systems are meant to be gamed, after all. Still, I think it's worth considering.
In a way, it's the ultimate pay-for-performance. You walk into a room and come out with tangible evidence of your ability to help someone understand a difficult inevitability.
So who's with me? Our train leaves for DC in the morning.