EXECUTIVE SUMMARY

Providers can now bill Medicare for advance care planning, eliminating one important barrier to end-of-life conversations.

  • It is unclear whether other health insurance carriers will follow suit.
  • The CPT code includes advanced practice nurses.
  • Many providers still lack tools and training.

Ethics consults in the hospital setting are frequently called due to conflicts stemming, in one way or another, from the patient’s lack of advance care planning. Now, an oft-cited barrier to these important — but time-consuming — discussions has been eliminated: That of reimbursement.

Providers can now bill Medicare for advance care planning, according to finalized regulations from the Centers for Medicare & Medicaid services (CMS).1 “This is an important barrier to have overcome,” says Jane Jankowski, DPS, LMSW, director of the clinical ethics consultation service at Albany (NY) Medical Center’s Alden March Bioethics Institute.

Individuals are less likely to prefer life-sustaining treatment when there is no reasonable hope of recovery, notes Jankowski. “Yet it can be distressing to implement such preferences when there has not been discussion about these matters before a serious health crisis arises,” she says.

Having advance planning conversations before an episode of acute illness facilitates respect for individual autonomy — even if the patient later becomes too ill to participate in the discussion. “These discussions will become less frightening if end-of-life topics are raised routinely in the course of general care planning,” adds Jankowski.

Full effect is unknown

Thomas D. Harter, PhD, an associate clinical ethicist at La Crosse, WI-based Gundersen Health System, says, “The full implications of CMS’s ruling to pay for advance care planning are unknown at this point.” He didn’t expect the change to happen this quickly, or as a result of a CMS rule.

“We had some indications from different contacts in Washington, DC that there was significant movement over the past few years toward paying for advance care planning,” says Harter. However, he expected reimbursement to come about as a legislative action by Washington lawmakers.

“In the long term, this ruling is likely going to be a positive impact for advance care planning,” says Harter. If other insurance companies follow Medicare’s lead, it would strongly signal to providers that advance care planning is considered to be part of good patient care.

“The move toward paying for advance care planning will help cover the cost of resources needed to adequately provide this service to patients — namely, the time needed to have in-depth conversations,” says Harter.

In the short term, however, the ruling could place providers accepting a variety of healthcare insurances in a precarious position, financially speaking. Some organizations, including Gundersen Health System, have a single billing system.

“That is, we either bill for a service or not — regardless of insurance coverage,” says Harter. Thus, some patients with insurance that doesn’t reimburse for advance care planning could be surprised by an unexpected out-of-pocket charge.

“This could become a barrier to the practice of advance care planning,” says Harter. Fearing dissatisfied patients, some healthcare providers may feel it’s in their best business interest to continue providing the service free of charge — until coverage for advance care planning becomes the norm.

On a positive note, Harter sees the rule as an indication that CMS “is recognizing the importance of advance care planning in providing high-quality patient care to all persons, not just those near the end of life.”

Quantity, not quality?

While reimbursement is important, it’s no guarantee that providers have the tools or skills to engage in advance planning conversations, says Jankowski.

Joan M. Teno, MD, MS, a professor of medicine at University of Washington’s Cambia Palliative Care Center of Excellence, says a payment for service doesn’t mean that advance planning conversations will be examined in the context of quality. “I fear that this is only going to result in billing, but without knowing whether these are quality conversations,” she says. “I am doubtful that this will have an impact on end-of-life care.”

John You, MD, MSc, FRCPC, associate professor in the Departments of Medicine and Clinical Epidemiology & Biostatistics at McMaster University in Hamilton, Ontario, acknowledges that reimbursement “might possibly increase the quantity — but not necessarily the quality — of advance care planning. But maybe that’s still better than nothing.”

A recent pay-for-performance initiative to promote cancer screening by Ontario’s primary care physicians resulted in little improvement despite significant expenditure.2 “It turned out that providers who were already doing the screening did it more frequently, but providers who weren’t doing the screening still didn’t do it,” says You. “The same could be true of advance care planning.”

If providers are uncomfortable with advance care planning discussions, they will likely remain so even with financial incentives. “These conversations are not easy for patients, and they are not easy for clinicians either,” says You, adding that the greatest need is for clinicians to have more confidence in having these conversations.

Still, says You, “symbolically, it is super-important that a huge payer in the U.S. system is making a statement, that they needed to make this change, because advance care planning is so important.”

What matters with advance care planning is the quality of the conversations — not the quantity, or the speed at which those conversations happen, says Harter. He recommends the following approaches to facilitate high-quality advance care planning conversations:

  • The development and implementation of a full advance care planning program unique to the needs of the individual health system. “Such programs often require systems redesign,” says Harter. “Advance care planning does not typically fit well within the standard workflows of medical providers.”
  • Training ethicists, social workers, chaplains, and other healthcare providers to provide advance care planning conversations that are as objective and as value-neutral as possible. “While there are lots of different training programs, the one we developed and use in the La Crosse, WI, region has been shown in multiple research studies to be an effective system,” says Harter.3,4 The approach has generated large numbers of completed advance care plans and high-quality conversations. “When needed, these lead to treatment decisions that accurately align with patients’ treatment preferences,” says Harter.

Part of regular nursing care

Cheryl Peterson, MSN, RN, senior director for the American Nurses Association (ANA), a role which includes oversight of the ANA’s Center for Ethics and Human Rights, was particularly happy to see that advanced practice nurses are covered by the CPT code. “One of the big obstacles has been that time is money,” she says. “Being able to have some reimbursement to support this service is important.”

Nurses have been routinely engaging in these conversations without reimbursement, however. “Nurses were often doing it regardless, because it is such an important component of nursing care,” says Peterson. “Now, it will become so ubiquitous to be almost unremarkable — jut a regular part of nursing care.”

Peterson hopes reimbursement will encourage earlier conversations so patients are able to advocate for themselves. “This timing of when this dialogue occurs is important,” she says. “It has to occur early enough to allow the time for the care team to all be on board as they think of the plan of care moving forward.”

Peterson says such conversations are particularly difficult in cases where providers can’t really predict what the patient’s outcome is going to be, and it’s necessary to plan for a variety of possible outcomes. “But that’s exactly the time where we need to be having these crucial and critical discussions,” she says.

The goal is for patients, providers, and family to all be “in the same space — so if need be, we can act accordingly,” says Peterson.

REFERENCES

  1. Centers for Medicare & Medicaid Services, 42 CFR Parts 405, 410, 411, 414, 425, and 495 October 30, 2015. http://bit.ly/1XFuKDf.
  2. Kiran T, Wilton AS, Moineddin R, et al. Effect of payment incentives on cancer screening in Ontario primary care. Ann Fam Med 2014; 12(4):317-323.
  3. Pecanac KE, Repenshek MF, Tennenbaum D, et al. Respecting Choices and Advance Directives in a Diverse Community. J Palliat Med 2014; 17(3): 282-287.
  4. Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A. The effects of advance care planning on end-of-life care: A systematic review. J Palliat Med 2014; 28:1000–1025.

SOURCES

  • Thomas D. Harter, PhD, Associate Clinical Ethicist, Medical Research, Gundersen Health System, La Crosse, WI. Phone: (608) 782-7300, ext. 50708. Fax: (608) 775-1565. Email: TDHarter@gundersenhealth.org.
  • Jane Jankowski, DPS, LMSW, Director, Clinical Ethics Consultation Service, Alden March Bioethics Institute, Albany (NY) Medical Center. Phone: (518) 262-7125. Fax: (518) 262-6856. Email: jankowj@mail.amc.edu.
  • Joan M. Teno, MD, MS, Professor of Medicine, University of Washington, Cambia Palliative Care Center of Excellence. Email: jteno@uw.edu.
  • John You, MD, MSc, FRCPC, Associate Professor, Departments of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada. Phone: (905) 525-9140. Fax: (905) 521-4971. Email: jyou@mcmaster.ca.