Association of Advance Care Planning Visits With Intensity of Health Care for Medicare Beneficiaries With Serious Illness at the End of Life

Weissman, Joel S.; Reich, Amanda J.; Prigerson, Holly G.; Gazarian, Priscilla; Tjia, Jennifer; Kim, Dae; Rodgers, Phil; Manful, Adoma

doi:10.1001/jamahealthforum.2021.1829

Cited by 17 publications

(8 citation statements)

References 46 publications

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“…However, ACP billing represents a standardized proxy for ACP in a national sample; by measuring ACP billing rates, we are able to assess practices' realized or missed opportunities to take advantage of Medicare's ACP initiative. 52 Finally, our approach has potential biases. While our models account for a number of practice and beneficiary characteristics, we acknowledge the role of unobserved confounders.…”

Section: Discussionmentioning

confidence: 99%

Practice Billing for Medicare Advance Care Planning Across the USA

et al. 2022

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BACKGROUND: Medicare introduced billing codes in 2016 to encourage clinicians to engage in advance care planning (ACP) and promote goal-concordantend-of-life care, but uptake has been modest. While prior research examined individual-level factors in ACP billing, organization-level factors associated with physician practices billing for ACP remain unknown. OBJECTIVE: Examine the role of practices in ACP billing. DESIGN: Retrospective cohort study analyzing 2016-2018 national Medicare data. PARTICIPANTS: A total of 53,926 practices with at least 10 attributed Medicare beneficiaries. MAIN MEASURES: Outcomes were practice-level ACP billing (any use by the practice) and ACP use rate by practice-attributed beneficiaries. Practice characteristics were number of beneficiaries attributed to the practice; percentage of beneficiaries by race, Medicare-Medicaid dual enrollment, sex, and age; practice size; and specialty mix.KEY RESULTS: Fifteen percent of practices billed for ACP. In adjusted models, we found higher odds of ACP billing and higher ACP use rates among practices with more primary care physicians (billing AOR: 10.01, 95%CI: 8.81-11.38 for practices with 75-100% (vs 0) primary care physicians), and those serving more Medicare beneficiaries (billing AOR: 4.55, 95%CI 4.08-5.08 for practices with highest (vs lowest) quintile of beneficiaries), and larger shares of female beneficiaries (billing AOR: 3.06, 95% CI 2.01-4.67 for 75-100% (vs <25%) female ). CONCLUSIONS: Several years after Medicare introduced ACP reimbursements for physicians, relatively few practices bill for ACP. ACP billing was more likely in large practices with a greater percentage of primary care physicians. To increase ACP billing uptake, policymakers and health system leaders might target interventions to larger practices where a small number of physicians already bill for ACP and to specialty practices that serve as the primary source of care for seriously ill patients.

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Section: Discussionmentioning

confidence: 99%

Practice Billing for Medicare Advance Care Planning Across the USA

et al. 2022

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“…12 Another study showed that 21.9% of billed ACP discussions occurred in the last month of life among Medicare beneficiaries with serious conditions who died in 2017-2018. 11 Similarly, existing studies demonstrated that 60%-70% of ACP visits took place in the office setting among Medicare beneficiaries in 2016 and 2017 7,9 and the number of ACP claims billed with AWV among Medicare beneficiaries has increased from 2016 to 2019. 16 While informative, these studies did not examine how the timing and setting of billed ACP discussions have changed over time.…”

Section: Discussionmentioning

confidence: 99%

“…An early study using Medicare claims data found that 38.1% of decedents in 2017 had a billed ACP discussion within the last 30 days of death 12 . Another study showed that 21.9% of billed ACP discussions occurred in the last month of life among Medicare beneficiaries with serious conditions who died in 2017–2018 11 . Similarly, existing studies demonstrated that 60%–70% of ACP visits took place in the office setting among Medicare beneficiaries in 2016 and 2017 7,9 and the number of ACP claims billed with AWV among Medicare beneficiaries has increased from 2016 to 2019 16 .…”

Section: Discussionmentioning

confidence: 99%

“…10 Studies using Medicare claims data showed that 38.1% and 21.9% of billed ACP discussions occurred in the last month of life among general Medicare fee-for-service beneficiaries who died in 2017 and those with serious conditions who died in 2017 or 2018, respectively. 11,12 Other studies also showed that most billed ACP visits took place in the office setting in 2016 and 2017. 7,9 However, evidence is limited on whether the timing and setting of billed ACP discussions have changed in recent years.…”

Section: Introductionmentioning

confidence: 99%

“…CMS in effect encourages conducting ACP discussions early in the office setting by providing financial incentives for ACP discussions for all Medicare beneficiaries 65 years and older regardless of their illness and by waiving the ACP coinsurance and the Part B deductible when ACP claims are billed along with Medicare Annual Wellness Visits (AWV) 10 . Studies using Medicare claims data showed that 38.1% and 21.9% of billed ACP discussions occurred in the last month of life among general Medicare fee‐for‐service beneficiaries who died in 2017 and those with serious conditions who died in 2017 or 2018, respectively 11,12 . Other studies also showed that most billed ACP visits took place in the office setting in 2016 and 2017 7,9 .…”

Section: Introductionmentioning

confidence: 99%

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Timing and setting of billed advance care planning among Medicare decedents in 2017–2019

Gotanda

Walling

Zhang

et al. 2023

J American Geriatrics Society

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BackgroundThe Centers for Medicare & Medicaid Services (CMS) began to reimburse clinicians for advance care planning (ACP) discussions, effective January 1, 2016. We sought to characterize the timing and setting of first‐billed ACP discussions among Medicare decedents to inform future research on ACP billing codes.MethodsUsing a random 20% sample of Medicare fee‐for‐service beneficiaries aged 66 years and older who died in 2017–2019, we described the timing (relative to death) and setting (inpatient, nursing home, office, or outpatient with or without Medicare Annual Wellness Visit [AWV], home or community, or elsewhere) of the first‐billed ACP discussion for each beneficiary.ResultsOur study included 695,985 decedents (mean [SD] years of age, 83.2 [8.8]; 54.2% female); the proportion of decedents who had at least one billed ACP discussion increased from 9.7% in 2017 to 21.9% in 2019. We found that the proportion of first‐billed ACP discussions held during the last month of life decreased from 37.0% in 2017 to 26.2% in 2019, while the proportion of first‐billed ACP discussions held more than 12 months before death increased from 11.1% in 2017 to 35.2% in 2019. We also found that the proportion of first‐billed ACP discussions held in the office or outpatient setting along with AWV increased over time (from 10.7% in 2017 to 14.1% in 2019), while the proportion held in the inpatient setting decreased (from 41.7% in 2017 to 38.0% in 2019).ConclusionsWe found that with increasing exposure to the CMS policy change, uptake of the ACP billing code has increased; first‐billed ACP discussions are occurring sooner before the end‐of‐life stage and are more likely to occur with AWV. Future studies should evaluate changes in ACP practice patterns, rather than only an increasing uptake in ACP billing codes, following the policy implementation.

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A Quality Improvement Initiative for Inpatient Advance Care Planning

Sacks,

Murphy,

O’Malley

et al. 2024

JAMA Health Forum

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ImportanceThe Centers for Medicare &amp; Medicaid Services (CMS) implemented advance care planning (ACP) billing codes in 2016 to encourage practitioners to conduct and document ACP conversations, and included ACP as a quality metric in the CMS Bundled Payments for Care Improvement Initiative in 2018. Use of this billing code in the inpatient setting has not been studied.ObjectiveTo determine whether a quality improvement intervention to increase inpatient ACP is effective in increasing ACP billing rates or changing hospital treatment plans or patient outcomes.Design, Settings, and ParticipantsThis nationwide cohort study and difference-in-differences analyses compared changes in ACP billing, treatment, and outcomes in Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized and cared for by 3 different groups: practitioners employed by a national acute care staffing organization who underwent an ACP quality improvement intervention, nonintervention practitioners at the same hospital, and control group practitioners from other hospitals. Using data from the Master Beneficiary Summary File, acute care hospital stays for nonsurgical conditions were linked to Medicare enrollment, claims, and vital status data from 1-year preadmission to 1-year postadmission from 2015 to 2019. The ACP billing rates for each group were assessed for associations with 6 inpatient treatments and 4 outcomes. Data analyses were performed from January 2022 to December 2024.Main Outcomes and MeasuresBilled ACP conversations, receipt of intensive care and life support (intensive care unit admission, gastrostomy tube placement, mechanical ventilation, tracheostomy), treatment limitations (newly initiated do-not-resuscitate orders) and outcomes (discharge to hospice, inpatient death, 30-day postadmission death, and 1-year postadmission death).ResultsThe total study sample included 109 intervention hospitals, 1691 control hospitals, nearly 12 million Medicare fee-for-service beneficiaries aged 65 years and older, and 738 309 practitioners associated with admissions from 2016 to 2018. ACP billing rates increased more for the intervention (1.3% in preintervention to 14.0% in postintervention; P &lt; .001) than for the nonintervention (same hospitals) and control groups (odds ratio [OR], 2.6; 95% CI, 1.7-4.1 intervention vs control). Increased ACP billing rates were significantly associated with decreased rates of inpatient death in the intervention group (OR, 0.95; 95% CI, 0.90-1.00) compared to the nonintervention (OR, 1.10; 95% CI, 1.04-1.17) and control groups (reference). All other associations were nonsignificant.Conclusions and RelevanceThis nationwide cohort study suggests that while the ACP quality initiative increased ACP billing, changes in clinical outcomes were inconsistent with the hypotheses. Further study is needed to address questions regarding confounding by unobserved measures of care quality.

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Association of Advance Care Planning Visits With Intensity of Health Care for Medicare Beneficiaries With Serious Illness at the End of Life

Cited by 17 publications

References 46 publications

Practice Billing for Medicare Advance Care Planning Across the USA

Practice Billing for Medicare Advance Care Planning Across the USA

Timing and setting of billed advance care planning among Medicare decedents in 2017–2019

A Quality Improvement Initiative for Inpatient Advance Care Planning

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