The Centers for Medicare & Medicaid Services has approved payment for discussing goals of care with patients. The change was part of the Affordable Care Act, although the implications for anesthesiologists remains unclear. The pros and cons of the new policy will be debated Saturday during “Now That Medicare Pays for Discussions About Goals of Care, Should They Become a Routine Part of Preoperative Consent?”

Neal H. Cohen, M.D., M.P.H., M.S.

Many anesthesiologists express concern about discussions with patients and their families regarding goals of care and the implications on anesthesia management. Some anesthesiologists believe they should include discussions about the goals of care as part of routine anesthesia management. Advance discussions can help clarify the issues before surgery, ensure that all providers have a consistent perspective on goals of care and help ensure that the care provided is consistent with the patient’s wishes.

Other anesthesiologists believe that goals-of-care discussions are not their responsibility, but are more appropriately discussed by the primary care provider or surgeon. Anesthesiology might be part of the broader discussion, but it is not their role to initiate them.

“We are going to address this topic as a pro-con debate,” said the debate moderator, Neal H. Cohen, M.D., M.P.H., M.S. “There are clear differences of opinion here, but the real message is that discussions about goals of care are important and that Medicare now recognizes the value for patients and providers. The question is not whether these discussions should take place, but what role anesthesiologists should play.”

Dr. Cohen is Professor of Anesthesia and Perioperative Care, and Vice Dean of the School of Medicine at the University of California, San Francisco. The debaters are Michael Nurok, M.B.Ch.B., Ph.D., Medical Director of the Cardiac-Surgical Intensive Care Unit at the Cedars-Sinai Heart Institute, Los Angeles, and Nicholas Sadovnikoff, M.D., Assistant Professor of Anesthesia and Pain Management at Harvard Medical School and Co-Director of the Surgical Intensive Care Unit at Brigham and Women’s Hospital.

Medicare’s decision to cover goals-of-care discussions is in some ways nearly irrelevant and in other ways highly relevant to current anesthesia practices, Dr. Cohen said. The acknowledgement that these discussions are an important part of clinical practice is more important than the dollars that result from this change in Medicare payment. At the very least, providing reimbursement acknowledges both the importance and the validity of the patient perspective and patient preferences in the wider surgical picture.

On the other hand, the payment for discussions about goals of care may have significant implications for anesthesiologists in critical care and pain management settings. The availability of reimbursement reinforces the concept that the anesthesiologist may have a role in initiating the discussions with patients and families, or at least facilitating the discussions among other providers to ensure that goals are care are defined.

The financial impact of fees will depend on the overall roles and responsibilities of the anesthesiologists, surgeons and others who provide care for complex procedures. For some anesthesiologists, it will be an additional payment for something that is already part of routine anesthesia management, even if it has not been explicitly acknowledged, Dr. Cohen said.

For anesthesiologists who have not routinely discussed goals of care with patients, the additional payment would provide compensation for the additional time needed to actually have those discussions and may encourage this meaningful dialog, which has a great impact on clinical decision-making, he said.

“We know that attendees will have opinions on this matter,” Dr. Cohen said. “The discussion will provide an opportunity to express those opinions. We want to create a dialog among anesthesiologists as to where goals of care fit in their clinical practices, not only based on the payment changes, but more importantly to ensure that clinical care is consistent with patient goals.

“We are hoping it will help educate us all as specialists in anesthesia as to what our roles can and should be as we develop guidelines and practices to support the provision of patient-centered, value-based anesthesia care.”