Medicare Approves Payment for End-of-Life Counseling

October 31, 2015

By Robert Lowes 
October 30, 2015

A proposal too hot to handle in the nascent days of the Affordable Care Act (ACA) became a reality today when the Centers for Medicare and Medicaid Services (CMS) approved payment for voluntary end-of-life counseling as part of its 2016 Medicare physician fee schedule.

The new policy will help seniors “make important decisions that give them control over the type of care they receive and when they receive it,” CMS said in a news release.

The decision to pay for so-called advance-care planning (ACP) initially will fall to Medicare administrative contractors (MACs) that process claims on behalf of Medicare.

An early version of the healthcare reform law called for paying physicians under Medicare for ACP — that is, discussing advance directives, hospice care, and other end-of-life issues with patients. Supporters of the idea said it would address the problem of physicians not taking the time for such important conversations because they were not reimbursable in a fee-for-service system. However, that provision was dropped after ACA critics erroneously claimed that the law would establish “death panels” with the goal of reducing healthcare costs by culling sickly seniors from the population.

CMS reintroduced the proposal to pay for ACP to far less flak this summer in the first draft of its Medicare physician fee schedule for 2016. Today, the agency released the final version of the fee schedule, with the proposal intact.

The American Medical Association and many other medical societies support paying for end-of-life counseling, although the small but vocal Association of American Physicians and Surgeons contends that such fees would “create financial incentives to persuade patients to consent to the denial of care.”

In the final version of the fee schedule, CMS said it received roughly 725 public comments on its ACP proposal since it was first floated this summer. The agency noted that “the vast majority of comments indicate that most patients desire access to ACP services as they prepare for important medical decisions.”

Medicare Administrative Contractors Will Implement New Policy

There are two current procedural terminology (CPT) billing codes for ACP. CPT code 99497 covers a discussion of advance directives with the patient, a family member, or surrogate for up to 30 minutes. An additional 30 minutes of discussion takes the add-on code of 99498.

Under next year’s fee schedule, ACP also can be an optional — and reimbursable — element of Medicare’s annual wellness visit.

CMS is slowly easing into this new arrangement. Right now, Medicare has not made what it calls a “national coverage determination” on paying for ACP. That decision would be made instead by the MACs — many of which are commercial insurers — that process claims for Medicare. A CMS spokesperson told Medscape Medical News earlier this year that MACs normally would pay for the two new billing codes in this circumstance unless they took the trouble to contest them by issuing a Local Coverage Determination.

CMS said in its final 2016 fee schedule that it “may be advantageous to allow time for implementation and experience with ACP services” under the auspices of local MACs before the agency considers setting a “controlling national policy.”

More information about the final 2016 Medicare physician fee schedule is available on the CMS website.

Thought Terminating Cliches

October 3, 2015

by Terence T. Gorski

No Need To Think!

A thought terminating cliché is something that we memorize and start to use automatically that keeps us from thinking clearly and deeply about something. For example: “Screw it, I don’t need this now!” 

The key to identifying a thought terminating cliché is to recognize that we don’t really understand what the thought means and it turns off our thought process when we are confronting a problem that we really need to think through. As a result we become trapped using this thought terminating clichés to shut down our mind whenever we start thinking about something that makes us feel uncomfortable but that we need to confront in order to grow in our recovery.

We need tp recognize the difference between thought terminating clichés that stop us from thinking about issues we need to face, and healthy thought stopping commands that we use to turn off habitual irrational thinking, ruminations, and resentments.

In my definition of a thought stopping cliché presented above, it says very clearly tat it is: “something that we memorize and start to use automatically that keeps us from thinking clearly and deeply about something.” This is very different from thought redirecting phrases that have a deep personal meaning and change our way of thinking from old addictive thought patterns to new recovery supportive ways of thinking.

The slogans in 12-Step programs are a perfect example of thought redirecting phrases if they are used properly. And this is a big if! 

It is both “what we say to ourselves” and “how we have conditioned our brain / mind to respond to what we say to ourselves.” Let me explain. 

If our response to the slogan “Easy does it!” activates the belief “It’s OK to do nothing at all if I don’t feel like it!” the slogan is being used a a thought terminating cliche – a form of thinking without thought that gives us permission to only do what we feel like doing and not what we need to do to recover.  

If the same slogan “Easy does it!” helps us to start thinking about: 

• The need to slow down and lower stress;

• The importance of not biting off more than we can chew to avoid choking (Father Joe Martin’s concept of “not feeding spiritual steak to spiritual infants); 

• The real danger of running down as hill as fast as you can because it feels good in the moment while ignoring the long term consequence of falling flat on our face as gravity and momentum compel us to run faster than out legs can carry us; 

• Don’t take on so much that it takes us away from our recovery program and distracts us with other things we believe we must do now;; 

• We are not what we do! We are who we are as sober human beings. We are good people and it is OK to “just be and grow” in response toour spiritual voice within that tells us sobriety is necessary for us to stay alive and grow so staying sober need to come first.

If the phase Easy does It helps is to stop obsessively thinking addictive compulsive thoughts by telling ourselves to “do more and more and do it now or else” it gives us permission to slow down, turn off the mental chatter, practice patience, and just be.”

The question that determines the difference between thought stopping and thought redirecting is:

• “Does the memorized phrase stop me from thinking and reflecting on important issues that I need to face to move on in my recovery?. or

• Does the memorized phrase give me permission and motivational to go on doing self-defeating things that can lead to relapse? 

If the memorized word or phrase reminds me to stop and think about the new principles of recovery and personal responsibility it is a positive thought redirecting phrase because by thinking about it I am learning and growing in my recovery program.

If the memorized word or phrase keeps me locked into a pattern of addictive, compulsive and self-defeating ways of thinking it is a negative thought stopping cliché.

The difference between the two can be subtle and difficult to judge in the moment. This is why discussing our thinking with our sponsor, fellow members of our program, and at meetings is so important. These conversations about how to evaluate what we are thinking should, in the best tradition of recovery, teach us to think more clearly and rationally about addiction oriented versus recovery oriented thinking and behavior. This distinction is difficult to understand and even more difficult to explain (I feel I have not done the concept justice here and will keep working on an explanation that is more clear and easy to understand). It is a distinction, however, that is critically important to make in our own minds so we can learn how to manage our mental and emotional life in recovery. 

I will end with the words of one of my favorite singers and song writers, Harry Chapin, when he says in one of his songs: “Sometimes words can serve me well and sometimes words can go to hell!”

To Start Using Thought Redirecting Phrases In The Workbook

The Cognitive Restructuring for Addiction: 

Gorski Books:

Gorski Home Studies: 

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