Medicare reimbursement not yet boosting advance care planning

By Scott Baltic

NEW YORK (Reuters Health) - Medicare’s reimbursement for advance care planning (ACP) appears to have been “largely ineffective” at encouraging clinicians in the U.S. to discuss ACP with their patients, at least in the first three months after the reimbursement went into effect, a new study reports.

“While clinicians are open to using the reimbursement codes,” organizational barriers such as documentation requirements and low visibility “make it difficult for clinicians to bill for ACP,” the authors wrote in BMJ Supportive and Palliative Care, online June 21.

Still, they believe, “there is a symbolic role that this change can serve, and the policy could have more impact as its existence becomes more widely known.”

As of January 2016, Medicare started reimbursing clinicians for having ACP conversations with their patients at the rate of $80-$86 for the first 30 minutes and about $75 for each additional 30 minutes. (The CPT billing codes are 99497 and 99498.)

The report, by Dr. Gawin Tsai and Dr. Donald H. Taylor Jr. of Duke University in Durham, North Carolina, notes that according to previous research, patients often do not want aggressive care near the end of life. The paper also cites a 2014 poll that showed nearly 25 million Americans over age 50 have experienced “excessive or unwanted medical treatment.”

For the current study, the researchers identified 493 clinicians at a single center who were either primary-care physicians treating adults or cancer specialists, including nurse practitioners and physician assistants as well as physicians.

The authors then emailed these clinicians a five-question survey asking about their practice of ACP, their awareness of the Medicare change, and whether the change would affect their practice.

Ninety-nine clinicians (20%) completed the survey: 54 primary-care clinicians and 45 cancer specialists.

In the study’s second phase, the researchers conducted 28 semi-structured interviews with physicians.

The survey found that although 83% of responding primary-care clinicians reported having ACP conversations with their patients, only 35% knew about Medicare’s change to reimburse for ACP. Among the cancer specialists, 59% of respondents reported practicing ACP, but only 24% reported knowing about Medicare’s reimbursement change.

The main obstacles to more ACP engagement identified by the study included both structural barriers - such as uncertainty about how to document ACP and issues with the 30-minute increment specified by the billing code - and professional barriers, such as clinicians’ lack of comfort with having the conversation.

One primary-care physician who was interviewed said, “I think primary care physicians don’t want to deal with these questions, we think they should be managed by the specialists because they are providing the specialty care (for a disease) that is going to kill them . . . I think very often the specialist thinks, well I have only known this patient a short time, the primary care doc should do this.”

Both structural and professional barriers have to be considered, because breaking down just one or the other “will not significantly increase the number of ACP conversations healthcare providers have with their patients,” Dr. Tsai told Reuters Health by email.

“As providers become more aware of improving end-of-life care, they might want to have more ACP conversations with patients,” she added, but “structural barriers could still serve as major roadblocks to providers actually doing so.”

Dr. Taylor recommends two online resources. One, from the Centers for Medicare and Medicaid Services (CMS), explains ACP billing within original Medicare: https://go.cms.gov/2bWsju7.

The second, from the American Society of Clinical Oncology, includes a link to a PDF booklet (in English or Spanish) on ACP: https://bit.ly/2jUcz2L.

Given its low response rate and other limitations, this study came up with “kind of thin data,” yet it was still worth reporting, because there’s a lack of larger studies, Dr. Joanne Lynn, director of the Center for Elder Care and Advanced Illness at the Altarum Institute, Washington, D.C., told Reuters Health in a phone interview.

Most Medicare patients have chronic, ongoing conditions, and CPT codes for ACP, chronic care management and care transitions each have their own rules and might require a certain number of minutes, a certain type of practitioner and/or certain documentation, she explained.

Further, Dr. Lynn added, ACP involves much more than DNR instructions and is more complex than many physicians initially realize, potentially raising questions like “Who’s going to bring in groceries?” for an aging patient, or, Who will pay for a wheelchair ramp at the patient’s residence?

ACP, she continued, addresses the question “How are you going to live for this next period of your life?” and therefore results in “a much richer conversation, and a much more difficult one.”

As a result of these complexities, she concluded, “It will take a long time” for physicians to climb the ACP learning curve.

SOURCE: https://bit.ly/2tq0E0G

BMJ Support Palliat Care 2017.

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