In July 2015, the Centers for Medicare & Medicaid Services (CMS) released a proposed update to the physician payment schedule which includes a recommendation to make advance care planning services a separately payable service under Medicare.

Supporters of the proposed update were encouraged to submit comments in favor of the new rule before the Sept. 8, 2015 deadline. This recommendation is a game changer for Coalition for Compassionate Care of California supporters, and brings us one step closer to our goal of promoting high-quality, compassionate care for all Californians who are seriously ill.

Read CCCC’s letter of support below.


Strong Support for CMS-1631-P

The Coalition for Compassionate Care of California (CCCC) strongly supports the Center for Medicare & Medicaid Services’ (CMS) proposed rule to revise payment polices under the Medicare Physician Fee Schedule (PFS), specifically, the proposal to establish separate payment and a payment rate for two advance care planning services (CPT codes 99497 and 99498). Compensating healthcare professionals for time spent with patients in valuable conversations discussing treatment wishes and goals of care is a critical step forward in honoring patient treatment preferences, particularly those nearing the end of life.

CCCC is a statewide collaborative of healthcare providers, consumers, and government agencies working to improve care for seriously-ill Californians. In addition to extensive outreach and education, CCCC provides a variety of useful information and materials on advance care planning and end-of-life care on our websites at CoalitionCCC.org and caPOLST.org.

As the lead organization in California for advance care planning, including the Physician Orders for Life-Sustaining Treatment (POLST), we appreciate that CMS is recognizing the value and importance of advance care planning conversations between patients and healthcare professionals.

While we wholeheartedly support CMS’ proposal to reimburse providers for advance care planning discussions, we also encourage CMS to consider a national payment rate for advance care planning, rather than a state-by-state patchwork of funding. Further, we hope to see federal funding that supports a comprehensive network of care and services for patients with advanced illness, as well as extensive education and outreach to encourage providers to engage in quality conversations to help consumers in understanding their treatment options and expressing their wishes.

According to the Institute of Medicine’s (IOM) report, Dying in America, advance care planning should be the start of an ongoing dialogue between patients, family members, and healthcare providers about end-of-life care. This on-going dialogue requires healthcare providers to revisit a patient’s goals and preferences as their needs and intensity of service change over time. These crucial advance care planning conversations should:

  • Encourage thoughtful decisions about who the patient’s surrogate/decision-maker would be in the event a patient lacks decision-making capacity;
  • Facilitate the patient sharing his/her personal values and beliefs, goals for care, and key quality of life elements with their surrogate/decision maker, family and healthcare professionals;
  • Create documentation about patient treatment wishes, through both the patient’s medical record as well as by encouraging completion of an advance directive;
  • Offer the opportunity for appropriate populations to turn their treatment wishes into a medical order through the physician orders for life-sustaining treatment (POLST); and
  • Help ensure patients understand their options, including benefits and burdens of treatment options, based on their current health condition and prognosis, particularly for those individuals who we would not be surprised if they die in the next year.

Being able to bill Medicare and Medicaid for advance care planning conversations eliminates two key barriers to advance care planning mentioned in the Institute of Medicine’s (IOM) Dying in America report. First, healthcare professionals report that a “lack of time and lack of payment” are significant barriers to initiating advance care planning conversations with their patients. The new billing codes will support healthcare professionals in feeling more comfortable taking the time needed to educate patients about advance care planning and how to document their wishes. Second, the report indicates many people do not make their wishes known because they are uncomfortable with the topics of death and dying, and that “efforts are needed to normalize conversations.” (Key Findings, p.2). Providing payment will encourage healthcare professionals to make advance care planning conversations part of their regular interaction with their patients, which will help normalize these discussions.

Advance care planning conversations should not wait until someone reaches old age or receives a terminal diagnosis – these important conversations should be encouraged at all ages. An accident or sudden health crisis can happen at any age. An advance directive, which outlines general treatment wishes and can also be used to name a healthcare decision-maker, should be encouraged for anyone over the age of 18.

When an individual reaches a stage of significant frailty or advanced progressive illness, the conversations about end-of-life care plans become more specific and medical orders for life-sustaining treatment become important. The IOM report encourages states to develop and implement a Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in accordance with nationally standardized core requirements. California’s POLST program was implemented in 2009, and is now widely adopted across the state.

Advance care planning benefits society as a whole. It helps facilitate important conversations about end-of-life care, and eases family stress and confusion during medical crises. When people’s wishes are properly documented, they are more likely to receive the treatments they want and avoid those they don’t want, and healthcare professionals are less likely to provide unwanted and potentially burdensome treatments.

Conversation is an essential element in any advance care planning program. The POLST paradigm emphasizes eliciting, documenting and honoring patients’ wishes regarding treatments at end of life, and quality conversation is at the heart of this process.

With quality conversations in mind, we fully support the IOM’s recommendation that professional societies and other organizations develop quality measures for advance care planning conversations, and that payers tie these quality measures to reimbursement.

The CMS proposal to establish separate payment and a payment rate for advance care planning services reflects the growing recognition that advance care planning is an integral component of person-centered care. We strongly support this proposal, and hope that it is just the first step in an ongoing campaign to better support and encourage quality end-of-life conversations and care for all Americans.

Sincerely,

Judy Thomas, JD
CEO, Coalition for Compassionate Care of California

Karl Steinberg, MD, CMD, HMDC
Chair, Coalition for Compassionate Care of California

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