Executive Summary

Two new advance care planning codes are included in proposed changes to the 2016 Medicare Physician Fee Schedule.

• Providers would be paid for time discussing patient choices and completing necessary forms.

• The proposed rule accommodates the possibility of multiple conversations.

• Earlier, better conversations could decrease end-of-life conflicts.


 

Proposed changes to the 2016 Medicare Physician Fee Schedule includes a provision for two new advance care planning codes. These would be used to pay for a provider’s time discussing patient choices for advance directives and completing necessary forms.

“This wasn’t at all surprising. CMS [the Centers for Medicare & Medicaid Services] has been working on this ever since the initial proposal was derailed by ‘death panel’ discussions,” says David Casarett, MD, director of hospice and palliative care at Philadelphia-based Penn Medicine.

Last year’s Physician Fee Schedule rule established the codes, but did not make them active. “The active status now means that dollar values will be assigned during the rate setting step,” explains Judi Lund Person, MPH, vice president of compliance and regulatory leadership at National Hospice and Palliative Care Organization in Alexandria, VA.

Joan M. Teno, MD, MS, professor of health services, policy, and practice at Brown University’s Warren Alpert School of Medicine in Providence, RI, sees the proposal as “a good first step, but not sufficient. We must create incentives to ensure that patient preferences and goals are honored.”

Fewer end-of-life conflicts?

This proposal encourages physicians to have conversations about the patient’s goals of care — hopefully, long before an acute episode arises where the patient’s wishes and goals of care are needed for decision-making, says Person.

“It also covers advance care planning — both documents and wishes,” says Person. “When the patient’s physician knows their wishes, and they are documented, this definitely could have an impact on the number of conflicts that occur when no one knows the patient’s wishes.”

Advance care planning discussions are an ongoing process, rather than a one-time event, says Person. “We encourage conversations early and often, to cover the issues and concerns of the patient,” says Person. The proposed rule accommodates the possibility of multiple conversations, with a second code to be used for additional 30-minute increments.

The hope is that earlier and better conversations will ultimately prevent many end-of-life conflicts. “But many of these discussions are going to be far in advance of any crisis — sometimes years ahead,” notes Casarett. “Although we may see a decrease in difficult end-of-life situations, the main reason to do this is that it’s simply good medical care.”

This underscores the need for better training for healthcare providers. “I’m very interested to see how health systems respond to this — perhaps by creating advance care planning clinics,” says Casarett.

Person says that the most important thing is that patients and physicians will have clarity about patient wishes, and that patients’ wishes will be followed because they are known.

CMS is also considering making advance care planning an optional element of a beneficiary’s annual wellness visit. If this is the case, says Person, “there is a better chance that there will be thoughtful ongoing discussions that become a standard part of the visit. That is the best possible outcome.”

For healthy patients, this might mean simply choosing someone to make decisions about their healthcare for them if they were unable to, and discussing preferences in case of sudden catastrophic illness, says Alana Sagin, MD, an instructor for the Palliative Care Service at the Hospital of the University of Pennsylvania. For patients who are sicker, it might mean discussing their disease trajectory, potential complications, and eliciting care preferences including preferences to avoid potentially non-beneficial medical interventions.

“These conversations require anticipatory guidance from the medical provider,” says Sagin. “It makes perfect sense they would be a part of a visit with a patient’s primary care doctor.”

SOURCES

  • David Casarett, MD, Director, Hospice and Palliative Care, Penn Medicine, Philadelphia. Phone: (610) 617-2447. Email: casarett@mail.med.upenn.edu.
  • Judi Lund Person, MPH, Vice President, Regulatory and Compliance, National Hospice and Palliative Care Organization, Alexandria, VA. Phone: (703) 837-3122. Fax: (703) 837-1233. Email: JLundPerson@nhpco.org.
  • Alana Sagin, MD, Palliative Care Service, Hospital of the University of Pennsylvania, Philadelphia. Phone: (215) 460-7723. Email: Alana.Sagin@uphs.upenn.edu.
  • Joan M. Teno, MD, MS, Professor of Health Services, Policy, and Practice, Warren Alpert School of Medicine, Brown University, Providence, RI. Phone: (401) 863-9627. Email: joan_teno@brown.edu.