At Last: Getting Paid to Think!

Margaret Tempero
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You know, one of the first revelations I had as a fledgling faculty member and clinician was that internists, regardless of their specialty, didn't get reimbursed much for seeing and counseling patients. I was stunned. I might spend 2 hours with a new patient discussing their prognosis and their care and management, sometimes discouraging them from pursuing expensive tests and procedures, only to get reimbursed just enough to pay my clinic expenses. On the other hand, a clinician conducting procedures might perform a 15-minute procedure and take home a bundle! Never mind if the procedure wasn't known to be too effective—no payer ever questioned it, not even the federal government. How could that be? I didn't get it!

Well, thankfully now payers and consumers are starting to ask questions about the value and cost of treatment. That's an imperative. We must ask these questions because we can't sustain the rising costs of care, especially cancer care. But it's still largely a fee-for-service environment and you don't get reimbursed unless you perform some intervention. Medicare has never reimbursed clinicians adequately for cognitive services, even though there is a true cost for this. Helping patients navigate through and select appropriate options for their care takes time and effort.

But things are changing. This summer, the Centers for Medicare & Medicaid Services (CMS) announced a proposal that addresses this in part. Thanks to a bill called the Care Planning Act of 2015, sponsored by Senators Johnny Isakson (R-GA) and Mark R. Warner (D-VA), CMS is authorized to provide Medicare reimbursement for discussions with patients about their goals and preferences for end-of-life care. Assuming this proposal is blessed this month, payments will start in January 2016. I don't think this is an idea with too much controversy. Sure, some conservatives see this as a prelude to death panels and a way to scare patients out of selecting expensive treatment. But I hardly think that's going to happen.

For those of us in clinical oncology, these are hard discussions to have. Knowing that the time spent will be reimbursed makes it just a little bit easier to relax and take the time needed to do it properly. Believe me, you can't have these discussions without some knowledge of the patient as a person. And traveling through end-of-life care is a difficult journey. Every patient deserves a compassionate clinician who can spend the time required to address their concerns and anxiety.

The Care Planning Act has some other elements, too. It will allow for the testing of models for more intensive support services and will pay for the development of educational programs to encourage effective care planning. It directs the Department of Health and Human Services to develop quality metrics to measure concordance of patient preference with documented care plans. It also puts structures in place to help providers concentrate on care planning according to patient preference.

So I think this is a watershed moment in reimbursement policy and practice. We will finally get compensated for taking the time to be thoughtful and respectful of our patients' goals. Mind you, I think most oncologists are pretty adept at this already, despite the lack of specified payments for end-of-life discussions. But this new benefit will definitely help keep the lights on for financially strapped practices. And that's a very good thing!

Dr. Tempero is a Professor of Medicine and Director of the UCSF Pancreas Center, and the editor-in-chief of JNCCN. Her research career has focused on pancreatic ductal adenocarcinoma, especially in the area of investigational therapeutics.

Dr. Tempero has served on the ASCO Board of Directors and as ASCO President. She co-directed the AACR/ASCO Methods in Clinical Cancer Research and taught this course and similar courses in Europe and Australia. She was founding Chair of the NCI Clinical Oncology Study Section (CONC) and served as a member and chair of the NCI Board of Scientific Counselors Subcommittee A. She is on the External Advisory Boards of the Pancreas SPOREs at Mayo Clinic and at UAB/Minnesota and the GI SPORE at the University of Arizona. She is, or has been, on the Scientific Advisory Boards of the Lustgarten Foundation, the Pancreatic Cancer Action Network, the V Foundation, The Alberta Canada Cancer Board, and the EORTC. She served as a member of the Oncology Drug Advisory Committee for the FDA.

She has served as Deputy Director and Interim Director for the UNMC Eppley Cancer Center. She is Chief Emeritus of the Division of Medical Oncology at UCSF and served as Deputy Director and Director of Research Programs at the UCSF Helen Diller Family Comprehensive Cancer Center.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of NCCN.

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