As reported in this publication, Democrats have been quick to defend Donald Berwick's dead of night inclusion of advanced directive and end of life planning into what is called the Annual Wellness Visit (what most of us call a checkup). They claim it's purely voluntary and that Medicare already covers advanced directive discussions.
But the inclusion of the advanced directive and end of life planning is not voluntary, only the patient's discussion is. Doctors are required to bring it up year after year. What's more, noting that Medicare added the discussion of advance directives to the initial physical exam begs the question: why every year?
Indeed, the regulations dealing with "Medicare Coverage of Annual Wellness Visit Providing a Personalized Prevention Plan" goes out of its way to reject paying for other preventive evaluations because they are not "evidence-based" or lack standardized tools. This adherence to an evidence-based approach to coverage was used by Berwick to delay access to Provenge, the first vaccine for prostate cancer. And it is used to reject regular screening for hearing, depression, ability to successfully perform activities of daily living, fall risk, and home safety -- since none of those, according to Berwick's CMS, have enough current evidence.
So where is the evidence to support yearly review of advance directives and end of life care planning? Berwick cites three studies in the regulation to argue that end of life planning does not lead to harm. But that is beside the point on so many levels. The value and impact of advance care directives is suspect, to say the least: A recent systematic review of end of life planning found that most measures (of effectiveness) have not undergone rigorous development and testing.
Even worse, most research has focused on increasing the percentage of seniors filling out advance directives. Little work has been done on what difference it makes and whether, as Berwick claims, it improves the quality of life and reduces unwanted care. So, for instance, a 2005 review of advance care research found that "the usual practice of advance directives and advance care planning is supported by little reliable scientific evidence of efficacy in improving outcomes." What's more, the claim that "improved advance care planning actually improves the experience for patients and their families has only thin and equivocal evidence. The same can be said about the assertion that advance directives eliminate unwanted care or reduce cost. A major randomized trial and a review of several studies found that increasing the number of advance directives was not associated with a reduction in hospital resource use.
In fact, over the past twenty years the amount spent on life sustaining care has declined, as the number of people with advanced directives has increased along with the percentage of people who die with do-not-resuscitate orders. Medicare spending has not declined.
Why then is Berwick pushing now for annual advance directive discussions? First, the new regulation dovetails with the requirement that doctors use electronic health records to deliver advance directive materials to patients, annually. And it also overlaps with Berwick's stated desire to use the Web to deliver government-produced "shared decision-making" content about end of life care and as well as the use of invasive medical treatments.
While most of us will begin the New Year redoubling efforts to improve our health, 44 million Americans on Medicare will be hit with annual physician prodding and Google health links about making plans to die with dignity.
In Berwick's Orwellian world a wellness visit includes end of life care planning but not depression screening based on "the evidence." It insists on advance directives but ignores the fact that seniors are living longer than ever with fewer disabilities and should be encouraged to keep doing so. Instead the deranged definition of wellness -- and its rapid dissemination through our health records and the Web -- is all the medical information we need to know.
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