Financial Incentives to Increase Advance Care Planning Among Medicaid Beneficiaries: Lessons Learned From Two Pragmatic Randomized Trials

Abstract

Context. Medicaid populations have low rates of advance care planning (ACP). Potential policy interventions include financial incentives.Objective. To test the effectiveness of patient plus provider financial incentive compared with provider financial incentive alone for increasing ACP discussions among Medicaid patients.Methods. Between April 2014 and July 2015, we conducted two sequential assessor-blinded pragmatic randomized trials in a health plan that pays primary care providers (PCPs) $100 to discuss ACP: 1) a parallel cluster trial ( provider-delivered patient incentive) and 2) an individual-level trial (mail-delivered patient incentive). Control and intervention arms included encouragement to complete ACP, instructions for using an online ACP tool, and (in the intervention arm) $50 for completing the online ACP tool and a small probability of $1000 (i.e., lottery) for discussing ACP with their PCP. The primary outcome was provider-reported ACP discussion within three months.Results. In the provider-delivered patient incentive study, 38 PCPs were randomized to the intervention (n ¼ 18) or control (n ¼ 20) and given 10 patient packets each to distribute. Using an intention-to-treat analysis, there were 27 of 180 ACP discussions (15%) in the intervention group and 5 of 200 (2.5%) in the control group (P ¼ .0391). In the mail-delivered patient incentive study, there were 5 of 187 ACP discussions (2.7%) in the intervention group and 5 of 189 (2.6%) in the control group (P ¼ .99).Conclusion. ACP rates were low despite an existing provider financial incentive. Adding a provider-delivered patient financial incentive, but not a mail-delivered patient incentive, modestly increased ACP discussions. PCP encouragement combined with a patient incentive may be more powerful than either encouragement or incentive alone. J Pain Symptom Manage 2017;-:-e-. Ó

Does implementation matter if comprehension is lacking? A qualitative investigation into perceptions of advance care planning in people with cancer

“…Exploring ways to make sure this documentation meets legal and organisational requirements, yet represents patient wishes, is accessible and able to be updated will be paramount to the ongoing success and rollout of ACP. Much of the ACP literature focuses on ensuring high levels of implementation and uptake [12,13,24] but results of this study would suggest that comprehension is also important. A systematic review of interventions to improve participants understanding of informed consent for research found that multimedia interventions had limited success in improving patient comprehension, whereas having someone available to talk one-on-one to patients appeared to be more successful.…”

“…[10] Challenges include the desire to sustain hope in cancer patients, a lack of consensus about who in the clinical team should initiate discussions, complexities of prognostication and the process of decision making in ACP, and health professional, patient and caregiver time constraints. [11] Although intervention studies aiming to increase ACP documentation and adherence have been conducted, [12,13] it is still unclear how well patients engage with, and understand ACP. Not all patients have the health literacy (defined as the ability to seek, understand and utilise health information [14]) to reflect on their wishes, communicate and record them and update them as needed.…”

Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review

“…For Process outcomes, 21 of 29 (72%) were positive, including 20 of 27 (74%) for behavior change processes (e.g., readiness) ( Table 1). 17,23,46,92,101,126,127 For Action outcomes, 48 of 56 (86%) were positive, including seven of nine (78%) for patient reports of communication with surrogates 118,128 and clinicians 84,126,129 and 38 of 44 (86%) for ACP documentation. 17,80,120,125,127,130 For Quality of Care outcomes, 23 of 43 (53%) were positive.…”

“…In this context, a single ACP intervention would not be expected to positively affect all outcomes, which may be influenced by several other pillars. For example, a patientʼs ACP wishes may be moot if his/her surrogate is unprepared, community social norms do not support ACP, he/she lacks access to medical care, clinicians are untrained, health systems are not optimized to store and utilize ACP documents, and legislation is not optimized to help patients 128 or clinician, 84,126,129 or family reported 118…”

Is Annual Income a Predictor of Completion of Advance Directives (ADs) in Patients With Cancer

“…The ethics of requiring patients to complete ADs has been vigorously debated. 46 Policy initiatives, such as the use of defaults 51 or paying patients to complete ADs 52 complicate the ethical issue, perhaps especially when the goal is to increase AD completion in historically marginalized groups, including persons with lower incomes. Given the documented SES differences in AD completion, the role of household income should not be ignored in debates about the ethics of AD completion.…”