Advocacy

Quick Take on the 2017 Medicare Physician Fee Schedule: 5 Things You Should Know

By Phillip E. Rodgers, MD FAAHPM
Co-chair, AAHPM Public Policy Committee and Quality-Payment Working Group
AAHPM Representative, American Medical Association/Specialty Society Relative Value Scale Update (RUC) Advisory Committee

On Nov. 15, the Center for Medicare and Medicaid Services (CMS) published the 2017 Medicare Physician Fee Schedule (PFS) Final Rule. (Access a CMS Fact Sheet.)  Each year, the PFS designates how  – and how much – physicians and eligible billing practitioners get paid through the Medicare Part B program, which continues to cover roughly 70% of all Medicare beneficiaries (and many, if not most, of the patients seen by palliative care teams).

In recent years, AAHPM has been collaborating with specialty society partners and meeting with CMS officials to advance new codes that value non face-to-face work and more appropriately recognize the work of coordinating care for complex patients. So we were very pleased to see that earlier this year CMS proposed to include some of these codes in the PFS and make other significant changes that could positively impact palliative care teams. (Read AAHPM’s comments on the Medicare PFS proposed rule.) Nearly all of these proposals were just finalized and will become effective Jan. 1.  While it will take a few weeks to fully digest all the details in the final rule, here are five key changes for 2017 that you should know about:

1) New Payment for Advance Care Planning Services Provided via Telehealth. For those of you providing CMS-approved telehealth services (and you know who you are), you can now use the advance care planning (ACP) codes to bill for ACP services. While currently limited to patients in rural or health professional shortage areas, telehealth may expand significantly in the future.

2) 30% Increase in Payment for ‘Prolonged Face-to-Face Services’ in the Outpatient and Home Settings. Many HPM clinicians use prolonged face-to-face services codes to describe services like extended family meetings, time-intensive symptom management, and complex medical decision making. In 2017, payment for prolonged F2F services in the outpatient or home setting only, will increase by 30 percent.

3) New Payment for ‘Prolonged Non Face-to-Face’ Services. Starting in January 2017, Medicare will start making payment for significant ‘non face-to-face’ time spent in activities like reviewing patient records or interacting with referring clinicians, families, and interdisciplinary team members in preparing for (or following up on) an E/M visit in the hospital, clinic or home setting.  This is a potential game changer. As long as code requirements are met (e.g. at least 30 minutes spent on a single day, which may or may not be the same day as the related E/M code), billing practitioners can now get paid for this valuable and previously unreimbursed time.

4) New Payment for ‘Complex’ Chronic Care Management. Starting in 2017, Medicare will now start making payment for ‘complex’ chronic care management codes (CCCM):  99487 (first 60 minutes) and 99489 (each add’l 30 minutes). These codes reimburse time spent by non-billing clinicians (RNs, LPNs, medical assistants, social workers, spiritual care providers and others) in care outside face-to-face visits. Compared to the existing chronic care management code (99490, billable just once a month), these codes describe more involved services for more complex patients.  They also pay at a significantly higher rate and can be billed as many times as necessary to reflect the time spent during a given month.

There are important details about these services (beneficiary consent, cost-sharing, etc.) which need to be considered but, for palliative care teams that are providing care coordination services to their patients, this could be a significant source of new revenue to help support the interdisciplinary team.

5) New Codes and Payment for Behavioral Health Integration and Cognitive Impairment Assessment and Management. These are two big, new additions to the PFS that describe and value the work of psychiatric collaborative care (using psychiatrists and behavioral care managers in primary care practices) and assessment of cognitive impairment and dementia (which, notably, has a requirement to address advance care planning and palliative care needs of patients with cognitive impairment). These code sets have many moving parts and are worth getting to know well, particularly if you or others in your organization provide these specific services.

More importantly, these additions signal Medicare’s willingness to work closely with the provider community to break new ground in describing and paying for patient-specific, non-procedural services and could lead the way to describing other services (like, for example, palliative care assessment and management).

Well, if you’ve made it this far, bravo!  You may also be thinking:  Why should I care about this stuff, or the Medicare PFS at all?  It seems very complicated, confusing, and difficult to keep track of in my busy clinical life.  And isn’t fee-for-service dying anyway? Valid points, but I’ll leave you with two reasons to care.

First, fee-for service payments from Medicare (and the vast majority of commercial payers who follow Medicare’s lead) remain big sources of professional fee revenue for palliative care providers.

Second, while we are clearly moving to value-based reimbursement, the architecture of the PFS will remain very pertinent. The majority of the changes coming with implementation of Medicare’s new Quality Payment Program—through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways—are built on a fee-for-service chassis. This is intentional, and not only allows a smoother transition to new payment models but also retains what is still our best (if very imperfect) system to describe and value the work of clinicians caring for patients and families.

The 2017 Medicare PFS Final Rule makes measureable progress in this regard, and so deserves our attention. Review it with your favorite billing colleague or consultant, and see how you can take advantage of its new opportunities. In the meantime, AAHPM will both continue to work with stakeholder specialty societies to advance reimbursement for high-value, cognitive care services not currently described or paid for under the PFS as well as engage HPM thought leaders to support an Academy strategy aimed at advancing palliative care in emerging payment models.

Advancements on PCHETA Bill

Read the official press release from the Alzheimer’s Association and Hospice of Southern Maine.

Pingree, Collins, local agencies advocate passage of
Palliative Care and Hospice education bill

Legislation would provide expanded education, training, research and awareness of palliative care impact

SCARBOROUGH, Maine (Sept. 19, 2016) – Congresswoman Chellie Pingree joined representatives of the Alzheimer’s Association, Maine Chapter, Hospice of Southern Maine, Senator Susan Collins’ office and other organizations this morning at Gosnell Memorial Hospice House to support pending legislation, The Palliative Care and Hospice Education and Training Act (S. 2748/H.R. 3119 AKA PCHETA – https://www.congress.gov/bill/114th-congress/house-bill/3119/text).

“Access to high quality palliative and hospice care is so important to relieve suffering and improve quality of life for people with Alzheimer’s and other dementias,” said Rep. Pingree. “But the truth is there isn’t adequate training and education available to meet the need.  We must put more focus on training the palliative care workforce and invest in more research to make sure that patients and their families are getting the best possible care in times of their greatest need. This is an area where almost everyone has been affected in one way or another.”

Nearly half of all people with Alzheimer’s and other dementias are in hospice care at the time of their death. For people with advanced dementia, palliative and hospice care – which focuses on managing and easing symptoms, reducing pain and stress, and increasing comfort – improves quality of life, controls costs, and enhances patient and family satisfaction.

But, as the demand for such care grows with the aging population, more must be done to ensure an adequately trained workforce.

“Palliative and hospice care is a demanding field that requires a well-trained workforce of doctors, nurses, and other healthcare professionals,” said Senator Susan Collins in a letter. “Additional research is needed to develop and expand best practices for those with serious illnesses. The Palliative Care and Hospice Education and Training Act will accelerate our progress towards these objectives.

“We are proud to support the Palliative Care and Hospice Education and Training Act on behalf of the five million Americans currently living with Alzheimer’s disease and other dementias,” said Laurie Trenholm, Alzheimer’s Association, Maine Chapter Executive Director. “For persons in the advanced stages of this terminal disease, palliative and hospice care can improve both the quality of care and quality of life.”

“Increasingly, patients and families afflicted with Alzheimer’s, dementias and other serious diseases are realizing that there may be an alternative to aggressive hospitalization and invasive treatments that diminish quality of life,” said Daryl Cady, Hospice of Southern Maine CEO. “We believe that access to high quality palliative and hospice care is vitally important in helping relieve pain, managing symptoms and improve the quality life for all individuals. PCHETA is one important step towards ensuring more Mainers and Americans have access to this high-quality care.”

On September 24, Alzheimer’s Association, Maine Chapter and Hospice of Southern Maine both hold their biggest annual awareness events – The Walk to End Alzheimer’s in the morning at Payson Park and Twilight in the Park in the evening at Deering Oaks. This year’s cooperative day of events takes on new significance as both organizations support and raise awareness of PCHETA and the impact it brings to Maine.

Pictured above: Rep. Chellie Pingree (D-Maine) (pictured center) met today with Laurie Trenholm (left), Executive Director, Alzheimer’s Association, Maine Chapter and Daryl Cady (right), CEO, Hospice of Southern Maine for a press conference to support and raise awareness of The Palliative Care and Hospice Education and Training Act (H.R. 3119 AKA PCHETA).

About PCHETA
The Palliative Care and Hospice Education and Training Act (S. 2748/H.R. 3119 AKA PCHETA) is a bill to amend the Public Health Service Act to increase the number of permanent faculty in palliative care at accredited allopathic and osteopathic medical schools, nursing schools, social work schools, and other programs, including physician assistant education programs, to promote education and research in palliative care and hospice, and to support the development of faculty careers in academic palliative medicine.

About Alzheimer’s Association, Maine Chapter
The Alzheimer’s Association is the leading voluntary health organization in Alzheimer care, support and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer’s. Visit alz.org® or call 800.272.3900.

About Hospice of Southern Maine
Hospice of Southern Maine’s mission is to provide compassion, care, and comfort through end of life. Formed through a collaborative effort among York and Cumberland County leaders and health care providers, Hospice of Southern Maine (HSM) organized in 2001 and began providing direct patient services in 2004. Today, HSM cares for more than 1,500 patients annually, at the patient’s home, current care facility, or Gosnell Memorial Hospice House, an 18-bed inpatient facility in Scarborough. HSM admits patients with a variety of diagnoses, including Alzheimer’s; heart, lung, and kidney diseases; stroke; Lou Gehrig’s disease; and cancer. Care is patient-centered with family support, and provided by a comprehensive interdisciplinary team of physicians, nurses, social workers, aides, chaplains, grief counselors, and volunteers. Hospice of Southern Maine is a non-profit 501(c)3, Medicare certified, state licensed agency, and the largest provider of hospice services in Southern Maine. To learn more, visit www.hospiceofsouthernmaine.org.

For more information, please visit www.hospiceofsouthernmaine.org or www.nhpco.org.

For questions about this release, please contact

Kristin Melville
Hospice of Southern Maine
207-289-3658
kmelville@hospiceofsouthernmaine.org

Adam Lacher
Alzheimer’s Association, Maine Chapter
207-772-0115
alacher@alz.org

Advancing PCHETA: We Need YOU!

By Gregg VandeKieft, MD MA FAAFP FAAHPM
Chair, AAHPM Advocacy & Awareness Strategic Coordinating Committee

This week (4/5/16), Senator Tammy Baldwin (D-WI) (shown in photo addressing Academy leaders during AAHPM’s 2015 Capitol Hill Days) reintroduced the Palliative Care and Hospice Education and Training Act (PCHETA) in the U.S. Senate as S. 2748. The bill is already pending in the U.S. House (H.R. 3119) where it enjoys the support of 99 bipartisan cosponsors. Having served as co-chair of AAHPM’s Public Policy Committee the last two years, and as a regular member of the committee prior to that, it has been gratifying to see the advancement of this legislation that the Academy worked so long to develop.

PCHETA will help address the current palliative care workforce shortage by expanding opportunities for interdisciplinary education and training in the field, including establishing education centers and career incentive awards for physicians, nurses, physician assistants, social workers and other health professionals. The bill would also implement an awareness campaign, to inform patients and health professionals about the benefits of palliative care and hospice and the services available to support patients with serious or life-threatening illness, as well as direct funding toward palliative care research to strengthen clinical practice and health care delivery. (Access a bill summary.)

As a physician specializing in hospice and palliative medicine, I am excited about PCHETA’a potential to substantially impact the care of patients and families facing serious illness. At the same time, I’ve learned through my involvement in grassroots advocacy that the process requires focus and perserverence. An earlier, more limited version of the bill (the Palliative Care Training Act) was introduced back in 2004. We introduced an expanded PCHETA in Congress in 2012, and have reintroduced in each of the subsequent congressional sessions. This Congress, the bill was further expanded. AAHPM worked with other stakeholders to add new provisions related to nurse workforce training, palliative care awareness, and research funding.

We look to build support year by year… it’s just a part of the policy process. (I think this is what the German philosopher Max Weber meant when he described politics as the “strong and slow boring of hard wood.”)  Further, we know legislation like this rarely passes on its own. Bills are typically packaged together in a broader theme, so we’ll look for a vehicle to which PCHETA (or even parts of the bill) could be attached. In the meantime, it’s important to keep building momentum and to keep our eye on the goal. The introduced legislation offers us a chance to educate members of Congress about our field, our patients, and the need to expand access to palliative care and build the workforce accordingly. Reaching a certain threshold of support will allow us to push for a hearing. Getting lawmakers on board as cosponsors of PCHETA also builds visible support so, when the opportunity presents itself, there are members of Congress to push it over the finish line and know that people back home are watching.

So, today, I encourage you to take a moment to reach out to your elected officials and ask them to support PCHETA Policymakers need to understand the unique needs of patients with serious illness. Tell them your stories from the front lines of health care. Believe it or not – hearing from an “expert” constituent really does make a difference!

Here are a few ways you can be the voice for your patients and the field and help advance PCHETA:

  • E-mail your members of Congress and urge them to cosponsor PCHETA. Be sure to define and localize the benefit. An action alert with suggested talking points is available at AAHPM’s Legislative Action Center, making it easy to look up your lawmakers and send a personalized e-mail.
  • Engage in media outreach. You can write a letter to the editor (palliative care workforce needs; need for broader access to palliative care) or participate on social media (follow your member of Congress; use #PCHETA and #HPM)
  • Request time to meet with your members of Congress during the District Work Periods (they work in their district or state office about one week each month and are there many weekends) or attend a Town Hall meeting or other event in which your Member participates. Check out their websites, and sign up for their e-mail updates to learn of local events and opportunities.
  • Invite your members of Congress to visit your practice. This is a very effective way to directly show them what you do and the important impact on patient care.
  • If you already have a relationship with a federal lawmaker, or plan to be in DC and want help arranging a meeting with your members of Congress to discuss PCHETA, e-mail AAHPM’s public policy team at advocacy@aahpm.org.

Don’t forget the words of Thomas Jefferson, “We in America do not have a government by the majority. We have a government by the majority who participate.”

Medicare Pay for Advance Care Planning Doesn’t Fall That Short

By Phil Rodgers, MD FAAHPM
AAHPM Public Policy Committee Co-chair and RUC Advisor

Dr. Jennifer Brokaw’s article from Time magazine linked in the 11/10 SmartBrief concludes that CMS payment for advance care planning (ACP) services, that will start January 1, 2016, is inadequate to support the time necessary for physicians and qualified providers to provide advance care planning services. The article reaches this conclusion by citing that reimbursement amounts are limited to ‘initial’ palliative care consultation and ‘follow-up’ consultations, and thus do not allow payment for longer, more involved ACP and goals of care discussions.

Dr. Brokaw’s attention to the topic is very welcome, but her article may leave readers confused as to the use and value of the new CPT codes for advance care planning. Specifically, the new Current Procedural Terminology (CPT) codes would allow payment for ACP services of any length, including the long, complex discussions that are a practice staple of hospice and palliative care providers. 99497 (~$86) can be billed for the first 30 minutes of ACP services on a given day, and 99498 (~$75) can be billed for each additional 30 minutes of service performed on the same day, with no limit. There are no frequency limitations to these codes, so they may be used as often as the need arises.

They may be also be used in addition to most other inpatient and outpatient evaluation and management (E/M) codes, provided that the time counted to bill the ACP codes is only counted for ACP services, and not also used to meet time-based criteria for an E/M code. There are a few E/M codes (like those for some critical care services) alongside which the new ACP codes cannot be billed—so do read the fine print, preferably with your practice’s billing professional or consultant.

It is important to note that while CMS issued no specific documentation requirements for use of the new ACP CPT codes, they will be subject to audit. In fact, Medicare contractors may be watching a little more closely given that these codes are new, and there is an interest in making sure they are billed only when the services are delivered. As always, make sure you are documenting (in detail) the services that you perform.

I do agree with Dr. Brokaw that the new Advance Care Planning CPT codes are not a solution to better payment for advance care planning and palliative care services. They are, however, an important step in the right direction. In fact, AAHPM worked with other medical specialty societies to advance the new CPT codes for advance care planning, including presenting data from member surveys to the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) which suggested relative values for the codes to CMS.

For more information, please review the CMS fact sheet and full text of 2016 Medicare Physician Fee Schedule Final Rule.”

Organizational Advocacy Key to Promoting Advance Care Planning… Now it’s Time for Individuals to Make Their Voices Heard!

By Gregg VandeKieft, MD MA FAAFP FAAHPM
Co-chair, AAHPM Public Policy Committee

The following is part of a three-post progressive blog about advance care planning, prompted by the Centers for Medicare & Medicaid (CMS) decision not to pay for the new “complex” advance care planning codes in this year’s Medicare Physician Fee Schedule. Now is the time to tell CMS why you support reimbursement for these important services! The agency is accepting public comments through Dec. 30 —it’s easy to submit comments online!

Please also see AAHPM Public Policy Committee co-chair Phil Rodgers’ Pallimed post for detailed background on efforts to advance the new codes via the AMA RUC and with CMS, and read AAHPM State Policy Issues Working Group Chair Paul Tatum’s GeriPal post where he makes the case that it’s time for advance care planning to become routine for patients with serious illness.

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A common complaint in emergency departments and ICUs goes something like: “Why didn’t anyone ever talk with this patient about how serious their illness is? Is this really what they would have wanted?” Primary care providers and subspecialists who commonly deal with serious illness cite time constraints or fear that frank discussion of prognosis will “take away hope” as barriers. The unfortunate result is that things take a turn for the worse before the patient and their family have seriously considered or prepared for that possibility, and physicians with whom they have no prior relationship end up having “the talk” in the ED or after admission to the hospital.

Efforts to promote effective advance care planning (ACP) range from coordinated community-focused efforts, like the Gunderson Clinic’s Respecting Choices program to grassroots efforts like The Conversation Project. But what have medical specialty societies done to promote ACP? I’m proud to say that our Academy has been a leader on this front, particularly in terms of public policy advocacy.

For years, AAHPM has worked to advance federal legislation that would promote ACP. After his proposal to reimburse physicians for time spent in conversation about goals of care was cut from the draft health care reform bill amid cries of “death panels,” U.S. Rep. Earl Blumenauer (D-OR-3) invited key stakeholders – including AAHPM − to the table to develop comprehensive legislation on the matter. The result is the Personalize Your Care Act.

This legislation would provide coverage under Medicare and Medicaid for voluntary advance care planning consultations, make grants available for communities to develop programs to support “physician orders for life-sustaining treatment” to promote patient autonomy across the care continuum, require advance care planning standards for electronic health records, and allow portability of advance directives across states. The bill, which is cosponsored by U.S. Rep. Phil Roe, MD (R-TN-1), had bipartisan support in the House this past Congress, but it will need to be reintroduced next year. (Congressmen Blumenauer and Roe have met with Academy leaders for small-group dialogues during our annual Capitol Hill Days.)

At the same time, AAHPM has engaged in regulatory advocacy on the matter. The Academy joined with other medical society stakeholders to advocate for new CPT codes (included as 99497 & 99498 for 2015) for more complex advance care planning. AAHPM surveyed its members to contribute to findings presented to the AMA/Specialty Society Relative Value Scale Update Committee (RUC) which then developed and relayed relative value recommendations for the codes to CMS. (AAHPM was invited to survey under the American Geriatrics Society (AGS), which has a permanent seat on the RUC.) The Academy’s RUC advisor, Phil Rodgers, MD FAAHPM, has worked with representatives from AGS and other medical societies to strategize about how best to influence CMS staff and officials, and he participated in a meeting with CMS staff that stakeholder societies requested to explain why ACP is good medicine and urge CMS to reimburse these important services.

It’s been great to see other organizations also work to promote ACP. The American Medical Association’s (AMA) Code of Medical Ethics includes a section devoted to advance care planning, adapted from a more comprehensive report on ACP by the AMA’s Council on Ethical and Judicial Affairs. The American Society of Clinical Oncology (ASCO) has published a booklet on ACP, accessible in English and Spanish along with other materials, from a page dedicated to ACP on ASCO’s Cancer.Net web site. The American Geriatrics Society provides links to Prepare for Your Care, an on-line ACP tool for patients and families with excellent educational videos. A Spanish language version was recently added.

The American Academy of Family Physicians (AAFP) passed a resolution at its 2014 Congress of Delegates promoting the implementation of centralized registries for advance directives, durable power of attorney for health care, physician orders for scope of treatment (POLST), and do not resuscitate orders. The AAFP also has a position statement on “Ethics and Advance Planning for End-of-Life Care” that strongly encourages ACP and the completion of advance directives “as a part of routine outpatient health maintenance.”

But, if all these societies’ extensive efforts have yet to bring about the desired level of change, are further initiatives likely to be productive? Data from the “Respecting Choices” project confirm that communities can be positively affected by well-designed collaborative programs. Moreover, those of us practicing as palliative care specialists have an opportunity and responsibility to promote generalist palliative care skills among our colleagues.

Of course, with comments now being accepted on the 2015 Medicare Physician Fee Schedule Interim Final Rule – where CMS indicated it would not pay for the new CPT codes for advance care planning at this time (CMS states other codes can already be used for reporting and payment) – we, as individuals, have a unique and very valuable opportunity to weigh in with policymakers to explain why ACP is a vital medical service and how Medicare reimbursement not only serves to promote these important services for beneficiaries but, without separate codes, we are unable to track them to look at utilization, outcomes, and which specialties are performing ACP services and where.

I urge all my Academy colleagues – and everyone who cares about sound health policy – to take just a few minutes to submit comments to CMS by Dec. 30.

Phil Rodgers, who co-chairs the Academy’s Public Policy Committee with me, provides these tips for doing so:

  • Explain why you think it’s important to pay for ACP services through a specific mechanism. CMS has suggested that it believes Medicare already pays for ACP services through the Evaluation and Management (E/M) and extended service codes. Tell them about the unique value of advance care planning, and how it is ‘separately and identifiably’ necessary in addition to all other services (medical therapy, symptom management, etc.).
  • Be specific, be yourself, and write about what you know. It’s OK to reference the literature about ACP services and palliative care, the IOM report, the importance of tracking the frequency ACP is performed, the needs of an older and sicker society etc., but it’s more powerful to speak from personal experience. Tell patient stories that illuminate a connection between high quality advance care planning and better care for your patients. Every HPM professional I know has dozens if not hundreds such stories. Now is the time to tell them.

Moving PCHETA on Capitol Hill: A Q&A with the Academy’s Lobbyist

Years of Academy effort to develop legislation that expands opportunities for interdisciplinary education and training in palliative care paid off last summer when the Palliative Care and Hospice Education and Training Act (PCHETA) was introduced in Congress by Sen. Ron Wyden (D-OR) and Rep. Eliot Engel (D-NY-16). (Access a summary of the bill.) In March 2013, Sen. Wyden and Rep. Engel – PCHETA’s congressional champions – were joined by Rep. Tom Reed (R-NY-23) and additional cosponsors in reintroducing the bill (H.R.1339/S.641) in the new Congress, and they need stakeholders to help move PCHETA forward on Capitol Hill.

AAHPM Public Policy Committee Chair Stephen A. Leedy, MD FAAHPM, spoke with Sue Ramthun, a principal and senior vice president with Hart Health Strategies, AAHPM’s DC-based lobbying and consulting firm, about the bill’s chances in Congress and how individuals can help grow support for the measure. (Read more in the Summer 2013 issue of AAHPM Quarterly.)

Now that the bill has been reintroduced, what are the prospects for it passing?
An Act of Congress is no easy task. It takes a lot of education and attention to compete with the thousands of bills introduced each Congress. In the last Congress (2011–2012), 10,444 bills were introduced in the House and Senate, while 283 new laws were enacted (2.7% of the total). However, the statistics are deceiving, because legislation rarely passes on its own. Rather, bills are packaged together in a broader theme. Either way, it is important to build momentum and keep your eye on the goal. The introduced legislation is your vehicle for educating members of Congress about you, your patients, and palliative care workforce needs. Seeking support for PCHETA builds visible support so, when the opportunity presents itself, there are Members of Congress to push it over the finish line and know that people back home are watching.

What does it mean that the bill includes an “authorization” for appropriations ($49.1 million/year for 5 years)?
An authorization is the legislative term for giving permission in the law for a federal agency to spend money. Authorizations typically outline the amount of money that can be spent, for what purpose, and who may receive the money. In this case, up to $49.1 million in 1 year. The actual funding is determined through the annual appropriations process. There is no guarantee that a program is fully funded up to its authorized level. The appropriations committees may take into consideration whether a program is unauthorized, meaning it was never authorized or that its authorizing authority has expired. Entitlement programs, like Medicare and Medicaid, are treated differently since they are considered mandatory spending. However, discretionary health programs (e.g., National Institutes of Health, Centers for Disease Control, and public health programs) are subject to the authorization and annual appropriations process.

Some members of Congress say they won’t support a bill that adds to the federal budget. How do we address these concerns?
Congress is living under different budget rules than in the past. Currently, federal programs are subject to across-the-board cuts (sequester) to bring spending to the previous year’s level. Members of Congress are asked to support a plethora of worthy programs important to their constituents. Congress is required to offset increased spending with comparable reductions in other programs to pass a bill. Therefore, some Members are reluctant to support legislation that does not identify spending cuts in other programs. On the other hand, it’s difficult to find an offset that is easily supported by all. Therefore, it is imperative to educate, educate, educate—and support your arguments with data. A clear need must be articulated to change policy, with data to document the workforce shortage and resulting effect on patient access. That message is stronger coming from constituents so Members of Congress know of interest back home.

What can individual AAHPM members do to help advance this legislation?
Advocating for PCHETA is a shared responsibility. You can help by sharing your experience and stories. You are the constituent, the patient advocate, and the expert. Your Representative and Senators need to hear from you. The time you take from a busy practice is appreciated and makes a statement. Although it is nice to meet with your Representative and Senators in Washington, DC, there are many other opportunities to speak up without leaving your home or office. You can call and leave a message for the Member or ask to speak to their health legislative assistant. You can e-mail (regular mail is not as timely) via the AAHPM Legislative Action Center. Members of Congress work in their district or state office about 1 week each month and are there many weekends. You can request time to meet with them during the District Work Periods or attend a Town Hall meeting or other event in which your Member participates. Check out their websites and sign up for their e-mail updates to learn of local events and opportunities. You can also invite your Members of Congress to visit your practice. This is a very effective way to directly show them what you do and the effect on patient care. As physicians and other providers on the front lines of patient care, your direct communication and outreach to congressional offices helps them to better understand palliative and hospice care and the need to ensure an adequate workforce to meet current and projected needs. Developing these personal relationships with Members of Congress and their staff takes time, but results in a much better understanding of palliative care and its importance in the continuum of care.

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Access the Academy’s Legislative Action Center, and contact your representatives to ask that they sign on as supporters of PCHETA. Send an e-mail that combines your personal experience with hospice and palliative care and a few of the suggested talking points AAHPM has provided. If your members were cosponsors last Congress but have not yet signed on, you can send them a message expressing your gratitude and your hope that they will again support the bill now that it has been reintroduced. (Find out if your senators were past cosponsors here, and find out if your representative was a cosponsor here.) Share this link with any of your colleagues, and ask that they too weigh in with their members of Congress – you don’t have to be an AAHPM member to use the Academy’s Legislative Action Center.

The Role of Individual Advocacy in State Efforts to Promote Palliative Care

by Amjad Riar, MD

Nearly a decade ago, during my training as a third-year medical resident, one of my rotations in oncology was at Johns Hopkins. One of the responsibilities was to admit patients with advanced cancers, and I saw oncological emergencies for seriously ill cancer patients. This ignited the thought in my mind that — even in this state-of-the-art, world-class hospital providing excellent, disease-focused medical care — we are missing something relating to patient and family needs. Soon after my training was over, I began practicing as an internist but kept on exploring until I found the answer to my question, and that was a palliative care fellowship. I was excited that the answer meant patients in need would benefit from good pain control, effective symptom management, and an approach driven by their goals of care. But I realized that it is more complicated than I thought, when I found myself explaining to patients — and most commonly to other physicians — that palliative care is not about dying and is not only hospice, but is focused on all the things that can come before hospice. There wasn’t — and still is not — a single day in my practice that I don’t find myself explaining and trying to educate other docs about palliative care.

I have seen myself struggling with patients in so much pain and suffering from various symptoms in hospitals, and yet the attending physician is not interested in a palliative care consultation due to a lack of understanding about the focus and expertise of palliative care teams. This motivated me further. In hoping that one day I would see palliative care available to all patients and families and more education made available for all the stakeholders in health care, I realized the need for public policy advocacy and thought to approach the legislators in my home state of Maryland. I started calling their offices and writing letters with facts about palliative care … how it can lower health care spending while improving quality of life as well as quality of care. For two years, I tried to make the case to a few lawmakers. Most of them quickly concluded the conversation by saying that we already have hospice-related legislation, and they didn’t think a palliative care bill would get through that easily. Eventually, my persistence paid off, and I was able get through to one lawmaker who agreed to consider introducing a bill to mandate palliative care services in hospitals statewide. By this time New York’s palliative care legislation was already in place, so I had more real scenario to present.

The problem that I really wanted to address through legislation was patient and family access in acute care settings, along with provider — and general public — education. This required me to learn many new tactics and skills on how to lobby effectively. I had no idea how the legislative process works. I was asked by our state delegate to review the bill he drafted. After many meetings and fine tuning the language, we had crafted a measure we thought would be effective yet not controversial. It was ready for presentation to the House committee.

Now the real work started. This taught me even more, including an appreciation for how hard it can be to achieve something so right in your heart and mind but which may not make much sense to others. I called the office of each member of the committee and asked for an appointment, eventually meeting with all 23 delegates one on one. My goal was to educate each and every member of the committee in person before the bill came up for a hearing, to explain why this bill is needed and how the subject matter is different from what they may think. I created a “one pager” speaking to the issue and need. The bill could only move forward if there was a favorable report from the committee.

This certainly was a strenuous learning process. While the committee members came to have a good understanding of what the palliative care legislation was intended to achieve, we hit a stumbling block when a few members decided to postpone consideration of the bill. But, with continued advocacy and support from other organizations, the committee chair decided to create a workgroup to further discuss the measure. We met on regular basis and, eventually, my advocacy efforts all paid off: in this year’s session, a palliative care bill was passed in both the Maryland House and Senate. It is awaiting the governor’s signature.

The bill requires the establishment of at least five palliative care pilot programs in hospitals with at least 50 beds across the state. The programs are required to collaborate with palliative care or community providers to deliver care; to gather data on costs and savings to hospitals and providers, access to care, and patient choice; and to report to the Maryland Health Care Commission on best practices.

Of course, this is just a first step on the road in right direction… but at least we are on the road! Next steps are really focused on continued education and involvement of stakeholders. I am focused on building coalitions, continuing collaborations, and expanding palliative care services in long-term care and non-acute settings. I will keep you posted!

In the meantime, my message is this: One palliative care provider can make a difference!!

We know the number of patients with serious illnesses is only increasing. In today’s highly specialized and fragmented health care system, these patients walk a fine line from being the beneficiary of modern medicine to becoming its victim. Informed decision making, along with early involvement of palliative care, can potentially help these patients and their families to avoid the latter. Consider advocating for palliative care in your state. Get active in promoting better health care for our future generations. I will be very happy to share more about my experience so you don’t have to go through unnecessary steps that I may have. And if you decide to take action, you might just uncover personal stories where palliative care has impacted the lives of key policymakers and, in doing so, find a champion for your cause. The hard part is first taking the initiative. Once you do, however, remain persistent! You will be surprised to learn that persistence will pave the way to success. If you believe in something right, just go for it — and keep marching until you reach your destination!

Hospice and Palliative Medicine Commit to ‘Choosing Wisely’

by Larry Beresford

On February 21 AAHPM, on behalf of its members and the specialty of hospice and palliative medicine, joined with 15 other medical societies to introduce Round Two of Choosing Wisely, a major national health care quality initiative sponsored by the ABIM Foundation. In a health care system undergoing rapid reforms, serious turmoil and escalating demands to raise quality and reduce costs, palliative care is often offered as a solution for providing appropriate care more in line with patients’ and families’ goals, with fewer unwanted and unhelpful treatments and, frequently, lower overall costs. But increasingly, HPM will be asked to show the evidence for the quality and efficiency of its own services, just like other sectors of health care.

The Choosing Wisely campaign challenges participating medical societies to name five treatments that are frequently performed but often unsupported by the medical evidence—and to share this list with their members and the public. AAHPM accepted that challenge, and took its place at the podium on February 21 with other societies concerned about their place in the health care value equation. The latest issue of AAHPM’s Quarterly newsletter describes how the academy developed its list, who participated in that work, and how academy members can join in the campaign in their own communities and facilities.

Now we’d like to hear from you. What do you think of the Academy’s Choosing Wisely list? Are there other treatments of questionable value that you think are equally deserving of quality improvement interventions to target unnecessary utilization? What is being done in your work setting to promote the goals and values of the Choosing Wisely campaign?

Larry Beresford is a freelance medical writer from Oakland, CA, who specializes in hospice and palliative care issues.

POTENTIAL ENERGY. ACTIVATION. KINETIC ENERGY.

Some time ago, my AAHPM teammate (and social media maven) Jennifer Bose asked me if I’d write a blog post on my experience at the Assembly today. I’d be lying if said I was anything less than brimming with excitement about the prospect. You see, this is my second Assembly as a member of the AAHPM staff, and my first came just about a week after I was officially hired last year. Because I was brand new, I was able to experience Denver as an attendee might. I was given cart blanche and attended whatever session or meeting I desired. I saw everything. I met everyone. It was staggering and remarkably educational.

It was also decidedly different than my experience this year.

This year, I have been static, essentially posting up permanently at the Resource Center Advocacy Kiosk (you should check it out!). And, if I’m going to be honest, I have to say that I was a little worried about how my perception of this year’s Assembly might stack up after the exhilaration of last year’s. And if I’m going to be even more honest, I was really, really worried about identifying something interesting to put in a blog post. On its face, my activity at the Assembly thus far has really just amounted to sitting on a stool, behind a desk.

Fortunately, I was reminded today why the phrase “on its face” exists. It is a nod to the simple, yet essential truth that life must be lived to be understood, a warning against prejudgment. I was shown again that this Academy and the members who volunteer their time are, fundamentally, deeply dedicated to the field. I was shown again that I am lucky to work for such a special group of people, that hospice and palliative medicine practitioners are not like other providers.

Where policy and advocacy conversations at other specialties’ annual meetings may focus on increasing reimbursement or protecting turf, HPM practitioners seem to have one, core consideration in the issues they hold dear – the quality of care and life for patients and families facing serious illness. Almost every conversation I had with Assembly attendees today focused on what can be done to increase access to hospice and palliative medicine, to assess and improve the quality of care, to express to health policymakers and health system administrators how hospice and palliative medicine is systemically beneficial, and to increase the HPM workforce. Unsurprisingly, the focus was always outward, always on the needs of others.

I feel sometimes that a part of my job is to fret. The scope of policy activity at the state and federal level is daunting, and the list of areas in which I feel a responsibility to help AAHPM members make an impact seems to grow exponentially. Maybe this is a natural feeling in the information age, with its unsettling ability to turn unknown unknowns into (the far more frightening) known unknowns, but it’s unpleasant nonetheless.

Fortunately, though, I have an antidote – action. I always feel better when we are advancing the ball on an issue. I love listening in on a Public Policy Committee call or helping a member draft a letter or developing a project outline. I love it. It is the only way to turn those known unknowns into known knowns, and working with known knowns is really the only way to get your hands around an undertaking as vast as the one facing hospice and palliative medicine.

And that’s what I saw today – I saw the genesis of that action. I saw people who have been involved in advocacy for years, people who are just beginning and filled with all the zeal you’d expect, and I saw people who are primed and already planning how they are going to step up and advocate for their field. So, even though I was static pretty much all day, I was in the middle of a huge amount of activity. It was a cycle of sorts – Potential energy. Activation. Kinetic energy.

Patrick Hermes
Manager, Health Policy & Advocacy

Choosing Wisely in Hospice and Palliative Medicine

Has this happened to you? Your elderly patient can’t sleep their last night in the hospital before being discharged home with hospice care so the on-call physician orders a sedative-hypnotic. When the patient becomes confused and agitated, a CT scan of the head is ordered. Or how about this one: Your patient with stage IV non-small cell lung cancer is referred for screening colonoscopy. I’m sure you have your own stories. Experts estimate that one third of US healthcare spending, over $700 billion annually, is for care that is non-beneficial or even harmful.

Seeing treatments and tests reflexively ordered when the potential for benefit is low or the risk of harm is high, particularly for the elderly and people living with serious illness, was a major source of distress to me as a resident. That distress, and a belief that evidence-based medicine could guide us to care that is more effective, accessible, compassionate, and sustainable, lead me to a career in palliative medicine. It is precisely this hope that underlies the American Board of Internal Medicine Foundation’s Choosing Wisely® campaign.

The goal of Choosing Wisely is to challenge medical specialties to come up with their “top five” list of treatments, tests, or procedures that should be questioned because best evidence shows they are non-beneficial or even harmful. As a recovering molecular biologist, I confess, I devoutly believe that science that informs our compassionate care is the best way forward. All this is by way of explanation for the madness that overtook me when I agreed to serve as Chair of the AAHPM Choosing Wisely Task Force.

The challenge was significant. We had a relatively short timeline to build expert consensus on our list of “Five Things Physicians and Patients Should Question” in Hospice and Palliative Medicine. Striving for an inclusive and transparent process, we also wished to incorporate member feedback into the list development process. Fortunately, I was blessed with a wonderfully talented group of Task Force members.

To start the process we elicited suggestions for the list from the AAHPM SIGs as well as Task Force members. We used these to develop a short list of recommendations and then sought feedback from Academy members. We received close to 700 comments from more than 300 members ―vital input that informed the Task Force’s final selection of AAHPM’s recommendations and drafting of the precise supporting language for each item on the list. Finally, last Thursday, our recommendations were revealed – along with those of sixteen other medical specialties – during a press event in Washington, DC. (Visit choosingwisely.org to access the complete lists from all participating specialty societies and watch a video of the Feb. 21 announcement and panel discussion.) Each society, traditional and social media, along with Consumer Reports, Wikipedia, AARP, NHPCO and other consumer advocates are all contributing to the broad dissemination of the campaign.

With the final list announced, the real work now begins: supporting critical conversations between physicians and their patients as they collaborate to ensure the best care possible. To support those conversations, AAHPM has developed a set of talking points for members (login to Members Only required). Our AAHPM Choosing Wisely Task Force has also written a Special Article describing our “Five Things” in greater detail. Look for it in the March issue of The Journal of Pain & Symptom Management.

I’d also like to invite you to attend the Advocacy Forum at the AAHPM & HPNA Annual Assembly in New Orleans next month where my fellow Task Force members and I will discuss our Choosing Wisely recommendations and how you might choose to discuss them with your patients and the public. (Learn more.)

I’d love to hear your thoughts about AAHPM’s Choosing Wisely recommendations. What do you think of the list? Will you use it in the care of your patients? If so, how? What other recommendations would you like to see on any future lists?

Whether or not your “Five Things” list would be identical to AAHPM’s final version, I hope you find it a useful tool to engage patients, families, and the public in choosing wisely.

Daniel Fischberg, MD, PhD
Medical Director, Pain & Palliative Care Department, The Queen’s Medical Center
Chief, Division of Palliative Medicine, and Professor, Department of Geriatric Medicine, John A. Burns School of Medicine of the University of Hawaii
Honolulu, HI