Can We Induce Patients and PCPs to Execute Advance Directives?


Dr. Pullen wonders why more docs aren't encouraging patients to execute an advance directive and a medical durable power of attorney.

This article originally appeared online at, part of the HCPLive network.

You Get What You Pay For

Primary care physicians have come under criticism because they have not counseled their patients and encouraged them to execute an advance directive and a medical durable power of attorney. This is felt to be a factor in the leading to the large percentage of the dollars spent by Medicare in the last year, and especially in the last few days of life. There is pretty good data that appropriate use of hospice leads to both a higher patient satisfaction and lower costs than control groups of patients who do not use hospice in their last months and weeks. So given this, why doesn’t every patient come to their physician and demand to discuss end of life issues, and why doesn’t every primary care physician strongly encourage their patients to consider executing an advance directive and a medical durable power of attorney? It’s really pretty simple. Our health care reimbursement system gets exactly what it incentivizes.

If a senior patient chooses to make an appointment with their physician at any time other than at their Welcome to Medicare exam (a visit where since 2009 for a modest payment their physician is supposed to do a complete history, physical exam, EKG, discuss end of life issues and give counsel about advance directives and medical durable power of attorney) the patient is faced with paying the copayment and deductible portion of the fee for the visit, and the physician up until the current health care reform has not been able to bill specifically for these services. This has just been considered a minor detail to lump into a visit for hypertension, diabetes, or whatever else brings the patient to the physician.

It really would be quite simple to vastly increase the number of seniors with completed advance directives and medical DPAs. Just make it financially advantageous for patients to make this a part of a physician visit periodically, maybe every 5 years or more often if certain new diagnoses are made, and compensate the physician well enough that physicians will bring the subject up during visits. This could be as simple as making these visits fully paid for by Medicare (no copay, no deductible) if the visit includes counsel about advance directives and medical DPA, and the patient agrees to executes an advance directive and name someone as their medical DPA within 30 days of the visit. Also create a billing code to add to these visits such that the physician is paid 25% extra for the visit during which the counseling takes place. Allow this incentive only for outpatient visits. Once the patient is at the hospital it’s really too late to effectively accomplish much of the benefit of advance directives and medical DPAs. If this policy leads to a large majority of Medicare patients maintaining a current advance directive and naming someone as having their medical DPA, it could save big sums of money by avoiding the days in hospital ICU beds used by families to work through these issues, often without valid input from the patient involved. It might also increase use of hospice at appropriate times, leading to yet further savings. In addition it is incentivizing patients and physicians to address these issues before crisis is at hand. Even if there is no savings, it incentivizes both patients and primary care physicians to tackle this topic early and regularly.

There may be a better way to incentivize patients to execute advance directives and designate a medical DPA, and I’m all for someone thinking of a better way to do this, but most Americans are bright enough and frugal enough to take advantage of financial incentives, and I suspect most primary care physicians are too.

For any interested patients here is a link to a resource for all 50 states for advance directives.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at — A Medical Bog for the Informed Patient.

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