By Stacey Kusterbeck
Rates of advance care planning billing remain low, despite billing codes having been introduced by the Centers for Medicare and Medicaid Services (CMS) nearly a decade ago.1 Shortly after CMS made this change in 2016, a large acute care practitioner staffing organization implemented a quality improvement initiative to increase advance care planning billing. The initiative, which affected more than one million hospitalized Medicare beneficiaries, mandated education in advance care planning billing codes. Providers also received small financial incentives of $20 for completing advance care planning documentation. Additionally, for every patient admitted, providers were required to answer the question “Would I be surprised if this patient died in the next 12 months?”
“For providers, these conversations can elicit an adverse emotional state that triggers avoidant behavior,” says Olivia Sacks, MD, lead author of a study assessing the effect of the quality improvement (QI) initiative.2 Sacks and colleagues assessed advance care planning billing rates for Medicare beneficiaries 65 years of age and older. “Advance care planning conversations can be difficult for both the provider and the patient and family. For patients and their families who are not habituated into medical jargon, these decisions are complex,” says Sacks, a general surgery resident at Boston Medical Center. Families may say they want to do everything possible to prolong the patient’s life, but without a clear understanding of what it would mean, for example, to be tracheostomy-dependent or what it would mean to be in a long-term care facility. The study sample included nearly 12 million Medicare beneficiaries and 738,309 practitioners. The study was divided into three timeframes: After CMS added the billing codes but before the QI intervention was implemented; the year the intervention first was rolled out; and after the initiative was fully implemented.
Before the intervention was implemented, advance care planning billing rates were 1.3%, and increased to 14% after the intervention. Higher billing rates for advance care planning were strongly linked to lower rates of inpatient death in the intervention group. Notably, the initiative did not decrease end-of-life care intensity, such as mechanical ventilation, intensive care unit admission, or gastrotomy tube placement. “The findings were definitely surprising. We assumed that increasing the incidence of advance care planning discussions would at least increase the number of do-not-resuscitate orders or change a metric or two that could be considered a proxy of end-of-life care intensity. But perhaps we underestimate the power of clinical momentum — or overestimate the power of inpatient advance care planning discussions to change treatment,” suggests Sacks.
Ethicists can help physicians to become more comfortable with advance care planning conversations. “Ethicists can explore provider-associated barriers to advance care planning, such as lack of communication training or the discomfort providers feel in having these conversations,” says Sacks.
References
1. Luth EA, Manful A, Weissman JS, et al. Practice billing for Medicare advance care planning across the USA. J Gen Intern Med. 2022;37(15):3869-3876.
2. Sacks OA, Murphy M, O’Malley J, et al. A quality improvement initiative for inpatient advance care planning. JAMA Health Forum. 2024;5(10):e243172.
Rates of advance care planning billing remain low, despite billing codes having been introduced by the Centers for Medicare and Medicaid Services nearly a decade ago.
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