In Reply: I agree with Dr Hilty that low and delayed reimbursement can make it difficult for patients to receive the type of care they desire and likely contributes to continuing chemotherapy until death is imminent, when there are no other options but to switch to hospice at the last moment.
In addition to the delays and low reimbursement, Medicare may deny palliative care as a second charge if a patient is separately billed by an internist for treatment of heart failure. Medicare and other payers have a code for a family meeting to discuss goals of care (code 99367-99368; team conference, no direct patient and/or family contact), which is often critical to informing the family about current circumstances, options, and goals. Such meetings may be contentious and lengthy. However, there is no payment associated with that code. For a physician to be reimbursed, the only current option would be to hold the meeting at the bedside with the patient present, even if he or she is comatose or declaring that he or she did not want to know the information.