Understanding The Use Of Medicare Procedure Codes For Advance Care Planning: A National Qualitative Study

Ladin, Keren; Bronzi, Olivia; Gazarian, Priscilla; Perugini, Julia M.; Porteny, Thalia; Reich, Amanda J.; Rodgers, Philip T.; Perez, Stephen; Weissman, Joel S.

doi:10.1377/hlthaff.2021.00848

Cited by 19 publications

(22 citation statements)

References 24 publications

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“…Primary care-focused practices may be more incentivized to bill for ACP than specialty practices, which may focus billing efforts on higher-paying procedures than ACP. 23 Our findings that larger are more likely to perform ACP billing yet have lower use rates suggest an opportunity to increase ACP billing uptake in larger practices where a small number of PCPs already bill for ACP; it may be easier to maximize information sharing and increase uptake of clinical approaches within groups where some physicians have already adopted it. [19][20][21] Additionally, our findings that relatively few physicians in other specialties billed for ACP suggest an opportunity to expand ACP by targeting physicians and practices specializing in cardiology or oncology, for example, that care for seriously ill beneficiaries, and in many cases serve as those patients' primary source of care.…”

Section: Discussionmentioning

confidence: 82%

“…15 Alternatively, clinicians-and specialist physicians in particular-may forego ACP billing, even if they discuss ACP with their patients, because these codes are reimbursed at much lower rates than other services they may provide such as procedures. 23 Practices may lack the resources needed to bill for ACP, 14 such as leadership support for ACP billing, dedicated billing champions or personnel, or electronic health records that support documenting and billing for ACP. 13,[22][23][24] Larger practices and practices with a greater percentage of PCPs had higher odds of billing for ACP, although ACP use rates were lower in the largest practices.…”

Section: Discussionmentioning

confidence: 99%

“…23 Practices may lack the resources needed to bill for ACP, 14 such as leadership support for ACP billing, dedicated billing champions or personnel, or electronic health records that support documenting and billing for ACP. 13,[22][23][24] Larger practices and practices with a greater percentage of PCPs had higher odds of billing for ACP, although ACP use rates were lower in the largest practices. Presence of PCPs was the strongest predictor of ACP billing, and 95% of ACP claims were billed by a PCP or a nurse practitioner (most of whom are in primary care 36 ), whether or not that clinician provided the plurality of the beneficiary's visits.…”

Section: Discussionmentioning

confidence: 99%

“…[19][20][21] The role of practices in ACP billing utilization specifically is not well understood. 22 Qualitative studies indicate organizational factors such as administrative, documentation, and leadership support for ACP; [22][23][24][25] monitoring and benchmarking; 23 and training in conducting and documenting ACP 13,23,25 may influence ACP billing. To our knowledge, a large-scale quantitative analysis of organizational-level characteristics has not been conducted.…”

Section: Introductionmentioning

confidence: 99%

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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: 82%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Practice Billing for Medicare Advance Care Planning Across the USA

et al. 2022

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“…42,44,45 Recent research identifies a number of barriers to ACP billing, 44 including low reimbursement ($80 to $86 for the first 30 minutes and $75 for each 30 minutes thereafter, although ACP codes could be billed as often as needed) 46,47 and disruption to clinical workflow. 44 While explicitly incentivizing clinicians to have ACP conversations is a necessary first step to improving clinician-patient communication, it is clear that further reforms are needed, such as revising the ACP reimbursement structure and incorporating ACP in existing quality payment programs to allow for a more streamlined billing process and improved incentives. The latter could be accomplished by extending the Medicare reimbursement scheme for care planning for patients with cognitive impairment, which requires a written care plan for billing, to ACP.…”

Section: Planningmentioning

confidence: 99%

How Should Cost-Informed Goals of Care Decisions Be Facilitated at Life’s End?

Braun

Kakarala

et al. 2022

AMA Journal of Ethics

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Interventions near patients' deaths in the United States are often expensive, burdensome, and inconsistent with patients' goals and preferences. For patients and their loved ones to make informed care decisions, physicians must share adequate information about prognoses, prospective benefits and harms of specific interventions, and costs. This commentary on a case discusses strategies for sharing such information and suggests that properly designed advance care planning incentives can help improve communication and decision sharing.Case DD is the designated durable power of attorney for health care, who has served well in this capacity by prioritizing her mother's previously expressed wishes to the best of her ability. DD has also, to this point, represented all DD's siblings as they discuss with care teams the care of their elderly parent in hospital and nearing death. DD and the health care team have discussed initiation of life-sustaining interventions (eg, mechanical ventilation, intubation, artificial nutrition and hydration), as well as a hospice care referral, given the patient's diagnosis and impending death.DD explains to the health care team that her mother had previously indicated she wanted all lifesaving therapies but that she values quality of life over extended life. The patient had also expressed a desire not to become a family burden. While sharing this sentiment, DD expresses, "For long hospital stays, no one needs to know the price of services to know it's expensive and that it will leave us bankrupt-$100 a day, $1000 a day out of our pockets. That is too much for most American families and it's too much for us. Our kids won't be able to go to college, and we won't have enough to pay for my father's medicines. CommentaryHealth care in the United States, especially near the end of life (EoL), is extremely expensive. Medicare is the primary payer for health services rendered to patients over age 65 in the United States, and an estimated one-quarter of total Medicare spending is on about 5% of Medicare beneficiaries in their last year of life. 1,2 These statistics are

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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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Understanding The Use Of Medicare Procedure Codes For Advance Care Planning: A National Qualitative Study

Cited by 19 publications

References 24 publications

Practice Billing for Medicare Advance Care Planning Across the USA

Practice Billing for Medicare Advance Care Planning Across the USA

How Should Cost-Informed Goals of Care Decisions Be Facilitated at Life’s End?

A Quality Improvement Initiative for Inpatient Advance Care Planning

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