Recognizing Value in Advance Care Planning

End-of-life planning and care have received a lot of attention in recent months. In exploring ways to increase the value of healthcare both in terms of patient satisfaction and cost benefits, health policymakers have zeroed in on end-of-life care expenditures. The Centers for Medicare & Medicaid Services (CMS) has found that over 25% of Medicare healthcare spending can be attributed to 5% of Medicare beneficiaries who die annually. The goals of policymakers who are pushing for care planning are to identify a patient’s end-of-life preferences early, and to ensure that subsequent care aligns with these wishes.

Patient Preferences for End-of-Life Care

This first goal of identifying patient preferences has just been finalized in the Medicare context in CMS’s 2016 Physician Fee Schedule. The American Medical Association’s CPT Editorial Panel created 2 codes for advance care planning services for 2015.

On October 30, 2015, CMS finalized its proposal to begin reimbursing providers for advance care planning discussions. Advance care planning includes face-to-face discussions related to end-of-life decisions with patients, family members, or their surrogates. In the oncology setting, advance care planning may also include discussion of short- and long-term options, pain management, and hospice and palliative care.

The goal of advance care planning is the reduction in provision of unnecessary medical services or medical services that are inconsistent with a patient’s care goals. With acute care as the standard treatment in hospitals, and the tendency for patients who are at a near end-of-life stage to receive such acute care from a provider they do not know, it is key that patients plan ahead and complete standard forms regarding their preferences for end-of-life care.

In the individual state setting, advance care planning is also taking root. Several state laws have passed to provide easier documentation of end-of-life care goals in patient medical records. States provide for patients the option of creating advance directives or living wills, and healthcare powers of attorney to document preferences and designate a proxy healthcare decision maker.

Some states also have created registries for these documents, ensuring they will be readily available to healthcare providers as needed. The Institute of Medicine’s recent report, “Dying in America: Improving Quality and Honoring Individual Preferences Near End of Life,” notes that some providers have concerns about malpractice liability when honoring a patient’s advance directive. Although the report notes that such lawsuits are very rare, it does recommend state legislation to explicitly create a safe harbor for physicians who avoid unwanted treatment consistent with a patient’s advance directive. The Association of Community Cancer Centers (ACCC) will watch for such legislation as state sessions begin in early 2016.

Aligning Care with Patients’ Preferences

In addition to identifying patient preferences, the related goal of aligning care with patient preferences is receiving attention. Most notably, private payers and, recently, Medicare, have recognized the benefits of expanded access to hospice care. Previously, patients facing a terminal diagnosis were faced with the difficult choice of entering hospice or continuing curative treatment.

This July, CMS announced the Medicare Care Choices Model, expanding to 141 hospices nationwide of a pilot project that permits patients to receive end-of-life care and counseling at the same time they receive life-extending treatment.

This concurrent care model is already being tested by several private insurers and is showing high patient and family satisfaction, as well as substantial healthcare savings. If the Medicare experiment is successful, we can expect this model to be utilized in state Medicaid programs and by additional private payers.

Increased Utilization of Advance Care Planning

These efforts will go a long way to increase utilization of advance care planning, but there is still more work ahead. The Care Planning Act of 2015, S. 1549—recently reintroduced by Senators Mark Warner (D, Virginia) and Johnny Isakson (R, Georgia)—identifies several areas where additional effort will be needed to fully incorporate advance care planning into Medicare, and the US healthcare system broadly.

The Care Planning Act provides for the establishment of a national public education campaign to raise awareness of the need for advance care planning, as well as the development of training resources and decision-making aids.

End-of-life decisions inherently must be dictated by the patient, and patient education and awareness is critical in expanded use of advance care planning. The Care Planning Act also calls for the development of quality metrics, to ensure advance care plans are fulfilled as patients reach end-of-life. The effectiveness of care planning can only be realized if the patient’s wishes are truly respected.

Finally, the act calls for improved portability of advance directives, with the aim of including the advance directive in a patient’s medical record, as well as providing for deference to an advance directive executed in a state other than the state of care delivery.

We have clearly come a long way in recognizing the benefits of advance care planning and end-of-life care counseling in recent months. ACCC will continue to watch these initiatives and weigh in with the oncology care provider perspective.

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