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.