Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, May 08, 2008

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.


At Thu May 08, 06:58:00 AM, Blogger Christian Sinclair said...

Interesting suggestion #1D. As a palliative care doctor who has many of these conversations, the primary structure is billing for time, since these conversations can often take more then 30 mins (inpt or outpt) if you are going to do them right with compassion and time for explanation. Basically a very extended informed consent.

As far as other palliative care based 'procedures' I think the other one that ought to have a separate billing code is palliative (terminal) extubations. Being at the bedside of a patient to ensure their comfort with appropriate titration of medications, explain what is going on to the family, and support the rest of the ICU staff takes a lot of time as well. Going back to the days of 'titrate morphine to comfort' and leaving it all on the ICU nurses is walking away from our professional duties.

But one must look at the unintended consequences, as the public might begin to see this or your other idea of NHP=DNR as an undermining of the profession as we would then get paid for a new 'never event', death. I will bring this up on Pallimed and see what the palliative care community thinks of your ideas.

At Thu May 08, 10:30:00 AM, Blogger The Happy Hospitalist said...

In a way, it kind of is paid for. For hospital follow up visits, establishing DNR on the day you have the discussion is considered "high risk" in determining whether your patient gets a level 3 (99233) code. But you still need to get 4 points in the diagnosis section or 4 points in the data section to qualify for a highly complex visit. And you still need to qualify for a 99233 based on either history or physical exam. So in a way, it is "paid for", but in reality, you still have a bunch of other hoops to jump through to get a 99233 code past the fraud police.

At Thu May 08, 04:26:00 PM, Blogger Clinton said...

Interesting proposal.

Have you heard the "I wanna be a DNR" song? It could be the ICU theme song, as morbid as that sounds (and I imagine, insensitive by the general public.)

At Thu May 08, 05:16:00 PM, Blogger #1 Dinosaur said...

HH: In a way, it kind of is...

That's why it needs to be its own separate code, paid without bundling.

Clinton: Yeah, I've seen it. Cute.

At Thu May 08, 11:10:00 PM, Anonymous Anonymous said...

Since I paid my attorney about $350 an hour to draw up a health care power of attorney and an advance health care directive, it seems only reasonable that my MD should get paid to discuss the details with me. The directive is very generic - basically a yes/no check box with my name inserted into the pre-designed template. Better than nothing, but not adequate for complex, difficult decisions. So, as a member of the health care public I say YES, find a way to get paid for your time!

At Wed May 14, 10:25:00 PM, Blogger Dragonfly said...

That is a very interesting proposal.
As Christian Sinclair said, it could be misinterpreted. It is a good thing that there is so much more dialogue about this now, both for patients and the health care provider.


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