Ethical Considerations About Clinician Reimbursement for Advance Care Planning

Abstract

The Centers for Medicare and Medicaid Services (CMS) introduced 2 Current Procedural Terminology (CPT) codes that allow clinicians to bill for time spent discussing advance care planning (ACP) effective January 1, 2016. As defined by Sudore et al,1Sudore R.L. Lum H.D. You J.J. et al.Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel.J Pain Symptom Manage. 2017; 53: 821-832.e1Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar ACP is “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care….[with] the goal…that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.” Proponents applauded this new policy as a method to incentivize ACP, potentially increasing the uptake of ACP and thereby improving the delivery of medical care that aligns with the patients’ goals, values, and preferences.2Carr D. Luth E.A. Advance care planning: contemporary issues and future directions.Innov Aging. 2017; 1: 1-10Crossref PubMed Scopus (45) Google Scholar The purpose of this article is to examine the 2016 reimbursement policy through the lens of the ethical principles at stake: beneficence, autonomy, and justice, by considering conflict of interest, quality not quantity of CPT coding, and potential disparities that may occur. Following several years of deliberation, the CMS approved 2 CPT codes for ACP in January 2016. The CPT code 99497 allows clinicians to be reimbursed $80 to $86 for the first 30 minutes of a face-to-face conversation with patients and/or surrogates related to ACP. The CPT code 99498 allows clinicians to be reimbursed $75 for each subsequent 30-minute increment in time. Physicians, nurse practitioners, or physician assistants of any specialty may use these codes to bill for ACP. Additionally, clinicians can bill for conversations in outpatient, inpatient, or nursing home settings, provided these discussions take place in person. The CMS also expects that certain activities be documented in the patient’s medical record, including (1) total time of discussion in minutes, (2) that the patient or surrogate was given an opportunity to decline the discussion, (3) who was involved in the discussion, (4) some detail about what was discussed, (5) spiritual factors, (6) understanding of illness and why specific decisions were reached, and (7) whether an advance directive was completed.3Institute for Healthcare ImprovementEnd-of-life care conversations: Medicare reimbursement FAQs.http://theconversationproject.org/wp-content/uploads/2016/06/CMS-Payment-One-Pager.pdfDate: Published 2016Date accessed: November 15, 2016Google Scholar For billing purposes, it is not a requirement that the patient or surrogate complete an advance directive. Many medical and surgical professional organizations supported the introduction of these new CPT codes.4Gurman A.W. AMA on Medicare's proposed plan to cover advance care planning [press release].https://www.ama-assn.org/content/ama-response-medicares-proposed-plan-cover-advance-care-planningDate: Published July 9, 2015Date accessed: December 13, 2016Google Scholar, 5Agrawal N. Sage J. Ollapally V. Provisions in the 2016 Medicare physician fee schedule that will affect surgical practice: an overview.Bull Am Coll Surg. 2016; 101: 11-17PubMed Google Scholar, 6American Academy of Family Physicians2016 Proposed Medicare physician fee schedule: AAFP lauds payment stability, action on advance care planning codes.https://www.aafp.org/news/government-medicine/20150713feeschedule.htmlDate: Published July 13, 2015Google Scholar The American College of Physicians has described ACP conversations as “the standard of care.”7American College of Physicians Internists support advance care planning codes included in 2016 physician fee schedule proposed rule [press release].https://www.acponline.org/acp-newsroom/internists-support-advance-care-planning-codes-included-in-2016-physician-fee-schedule-proposed-ruleDate: Published July 8, 2015Date accessed: December 13, 2016Google Scholar A letter of support for the CPT codes from the American Academy of Hospice and Palliative Medicine to the Secretary of Health and Human Services signed by 66 medical and health associations stated that published, peer-reviewed research shows that ACP leads to "better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression, and lost productivity.”8Rudolf P. Multistakeholder sign on letter in support of voluntary advance care.in: Burwell S.S.M. American Academy of Hospice and Palliative Medicine website. American Academy of Hospice and Palliative Medicine, 2015Google Scholar Advance care planning is particularly important for Medicare beneficiaries because many have multiple chronic illnesses and receive care at home from family and other caregivers, and their children and other family members are often involved in making medical decisions.4Gurman A.W. AMA on Medicare's proposed plan to cover advance care planning [press release].https://www.ama-assn.org/content/ama-response-medicares-proposed-plan-cover-advance-care-planningDate: Published July 9, 2015Date accessed: December 13, 2016Google Scholar,8Rudolf P. Multistakeholder sign on letter in support of voluntary advance care.in: Burwell S.S.M. American Academy of Hospice and Palliative Medicine website. American Academy of Hospice and Palliative Medicine, 2015Google Scholar These codes were intended to benefit patients and families by improving access to ACP conversations and increasing the occurrence of conversations because clinicians will be allowed to charge for the time spent discussing ACP. In this way, the codes were intended to reduce uncertainty and reliev[e] families with the emotional and financial burden of costly end-of-life care. Despite widespread support for these new CPT codes, there are several potential ethical tensions surrounding the use of the CPT codes, their positive and negative impact on patients and the public, and whether they can meaningfully improve goal-concordant care during serious or chronic illness. For example, although many physician organizations maintain that billing for ACP promotes patient autonomy, others worry that these changes could compromise patient interests or beneficence by incentivizing the completion of documents that limit patient care, potentially without the benefit of in-depth discussions of goals of care at the end of life. This situation would violate the principal of non-maleficence. Conflict of interest is defined as occurring when a person’s private interests conflict with his/her official responsibilities in a position of trust (Merriam Webster definition). Opponents of the CPT codes argue that physicians and health care systems may inappropriately overengage in ACP for the purposes of financial reimbursement. Financial incentives may lead clinicians to conduct nonbeneficial or even potentially harmful ACP conversations. Such nonbeneficial conversations may take place under several circumstances: (1) by clinicians who are unqualified to conduct such conversations, (2) by clinicians at inappropriate times, or (3) by clinicians at an unnecessarily high frequency. Advance care planning and advance directive completion can be nuanced. Many contextual factors and conversation components can substantially influence patient treatment preferences. Evidence suggests that patients welcome ACP discussions with their clinicians and want to know that their clinician is comfortable talking about death and dying.9Steinhauser K.E. Christakis N.A. Clipp E.C. et al.Preparing for the end of life: preferences of patients, families, physicians, and other care providers.J Pain Symptom Manage. 2001; 22: 727-737Abstract Full Text Full Text PDF PubMed Scopus (350) Google Scholar Patients are not compelled to complete advance directive documentation during these billed visits. In certain cases, these conversations may lead to advance directive completion or more specific decisions regarding treatments that a patient wishes to pursue or decline. In this way, ACP discussions foster autonomy provided they are used properly. Specialists may be highly qualified to conduct necessary and beneficial ACP conversations about specific, anticipated decisions for a chronic, progressive condition. In fact, disease-specific advance directives, such as those for amyotrophic lateral sclerosis, are lauded for precisely this reason.12Auriemma C.L. Chen L. Olorunnisola M. et al.Public opinion regarding financial incentives to engage in advance care planning and complete advance directives.Am J Hosp Palliat Care. 2017; 34: 721-728Crossref PubMed Scopus (4) Google Scholar In addition, many specialists may also act as primary care physicians for a group of patients—and such specialists may be optimally poised to engage in ACP with such patients. Although clinicians from a variety of specialties, including primary care, have utilized the CPT codes for ACP, it should be specifically noted that palliative care specialists have seen the highest uptake in 2016 and 2017.11Barnato A.E. Moore R. Moore C.G. Kohatsu N.D. Sudore R.L. Financial incentives to increase advance care planning among Medicaid beneficiaries: lessons learned from two pragmatic randomized trials.J Pain Symptom Manage. 2017; 54: 85-95.e1Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In a recently published study by Auriemma et al,14Volpp K.G. John L.K. Troxel A.B. Norton L. Fassbender J. Loewenstein G. Financial incentive–based approaches for weight loss: a randomized trial.JAMA. 2008; 300: 2631-2637Crossref PubMed Scopus (546) Google Scholar 90% of surveyed adults supported programs promoting ACP. Lay population participants were presented with hypothetical mechanisms to incentivize ACP, including payments dispersed directly to patients, insurance coverage contingent on completion of an advance directive, and different physician reimbursement structures. The physician reimbursement structures garnered the lowest support from participants, with only 23% of those surveyed supporting physician reimbursement vs 58% supporting patient reimbursement for completing an advance directive. Financial incentives can help patients overcome an up-front unpleasant activity (of contemplating death) in exchange for a future health benefit, much as they have been shown to increase weight loss and encourage smoking cessation.11Barnato A.E. Moore R. Moore C.G. Kohatsu N.D. Sudore R.L. Financial incentives to increase advance care planning among Medicaid beneficiaries: lessons learned from two pragmatic randomized trials.J Pain Symptom Manage. 2017; 54: 85-95.e1Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 12Auriemma C.L. Chen L. Olorunnisola M. et al.Public opinion regarding financial incentives to engage in advance care planning and complete advance directives.Am J Hosp Palliat Care. 2017; 34: 721-728Crossref PubMed Scopus (4) Google Scholar, 13Volpp K.G. Troxel A.B. Pauly M.V. et al.A randomized, controlled trial of financial incentives for smoking cessation.N Engl J Med. 2009; 360: 699-709Crossref PubMed Scopus (538) Google Scholar, 14Volpp K.G. John L.K. Troxel A.B. Norton L. Fassbender J. Loewenstein G. Financial incentive–based approaches for weight loss: a randomized trial.JAMA. 2008; 300: 2631-2637Crossref PubMed Scopus (546) Google Scholar If we consider the financial incentives from a justice perspective, one could argue that prioritizing patients for reimbursement would have been a more effective and fairer strategy to encourage uptake of ACP. Furthermore it would negate concerns about conflict of interest for clinicians jeopardizing beneficence and give precedence to patient autonomy. It is unclear if patients would be eager to participate in ACP conversations (and how the ACP conversations might change) if patients knew a priori that their clinician would be billing for and receiving reimbursement for such conversations. There is general agreement that promoting ACP conversations can benefit patients.18Institute of MedicineDying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies Press, Washington, DC2015Google Scholar However, measures of quality and clinical impact of encounters reimbursed for ACP remain elusive.2Carr D. Luth E.A. Advance care planning: contemporary issues and future directions.Innov Aging. 2017; 1: 1-10Crossref PubMed Scopus (45) Google Scholar,16Gallegos A. Final fee schedule includes payment for advance care planning.Caring for the Ages. 2015; 16: 1, 4, 5Abstract Full Text Full Text PDF Google Scholar To protect patient autonomy, patients must have a clear understanding of likely treatment decisions and options they might face as well as the potential clinical contexts in which they could receive them.17Dansicker A. Paying docs for end-of-life discussions: can monetary incentives change the failures inherent with physician-patient communication?.Saint Louis U J Health Law Policy. 2015; 9: 149-178Google Scholar It may be hard for patients to imagine diverse situations and account for all possibilities in an advance directive, and therefore, ACP discussions that do not focus on specifics are helpful.10Benditt J.O. Smith T.S. Tonelli M.R. Empowering the individual with ALS at the end-of-life: disease-specific advance care planning.Muscle Nerve. 2001; 24: 1706-1709Crossref PubMed Scopus (33) Google Scholar Patients must have the opportunity to ask questions and express concerns during discussions. There is always a potential risk that poor-quality ACP discussions could mislead patients into accepting care that is not concordant with their personal values and goals, or, conversely, declining interventions that they may desire under certain circumstances. For example, patients might inadvertently articulate that they would never want to be on a ventilator when a time-limited trial of life-sustaining treatment would be a medically acceptable option that aligns with the patient’s values. Although these limitations have been inherent in ACP since its inception, the new CPT codes, with resultant increase in the number of potentially poor-quality ACP conversations, have the potential of causing underinformed decison making to become more prevalent. Whereas metrics exist for assessing procedural performance (for example, postoperative infection data, length of stay, readmission rates, redo rates), no analogous metrics exist for evaluation of ACP on the individual level, let alone the population level. The introduction of billing codes alone is insufficient to ensure that high-quality care preference conversations are occurring and are available for future reference in decisions about end-of-life care, whether in an advance directive or in a clinical note. Therefore, it is critical that suitable metrics be developed and deployed. To improve the quality of ACP conversations, we must continue to emphasize clinician training and develop best-practice standards.18Institute of MedicineDying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies Press, Washington, DC2015Google Scholar Navigating ACP discussions requires not only knowledge of the potential interventions and morbidity that patients may experience but also sensitivity and an ability to invite open discussion about personal goals and values. Many clinicians report little or no training in these skills and may feel underprepared to engage in ACP with their patients.3Institute for Healthcare ImprovementEnd-of-life care conversations: Medicare reimbursement FAQs.http://theconversationproject.org/wp-content/uploads/2016/06/CMS-Payment-One-Pager.pdfDate: Published 2016Date accessed: November 15, 2016Google Scholar,19von Gunten C.F. Ferris F.D. Emanuel L.L. Ensuring competency in end-of-life care: communication and relational skills.JAMA. 2000; 284: 3051-3057Crossref PubMed Scopus (202) Google Scholar Minority communities and vulnerable populations generally have lower rates of ACP completion for a variety of reasons, including cultural and faith-based beliefs about end-of-life care as well as mistrust of the health care system and clinicians.20Caralis P.V. Davis B. Wright K. Marcial E. The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia.J Clin Ethics. 1993; 4: 155-165PubMed Google Scholar,21Cohen M.J. McCannon J.B. Edgman-Levitan S. Kormos W.A. Exploring attitudes toward advance care directives in two diverse settings.J Palliat Med. 2010; 13: 1427-1432Crossref PubMed Scopus (25) Google Scholar There is a substantial body of literature documenting that minority groups utilize health care less than the general population during most of their lifespan but more at the end of life. Clinician reimbursement for ACP could be viewed by these populations as incentivizing conversations to limit the care that members of these communities receive. Conversations with minority patients, especially those with limited English proficiency or low health literacy, may also require more time and sensitivity to cultural beliefs and practices—two things that clinicians may lack. Some may argue that incremental recognition and compensation for these conversations is better than none. However, one could contend that investing in this mechanism to improve goal concordance at the end of life ignores the inherent and glaring differences in ACP acceptability and uptake. Indeed, when Pelland et al22Pelland K. Morphis B. Harris D. Gardner R. Assessment of first-year use of Medicare’s advance care planning billing codes.JAMA Intern Med. 2019; 179: 827-829Crossref PubMed Scopus (22) Google Scholar analyzed uptake of ACP CPT coding among Medicare beneficiaries in New England, they found that Hispanic and Asian patients had a lower odds ratio of having had an eligible visit. Although ACP does tend to influence end-of-life care, it has many limitations.15Brinkman-Stoppelenburg A. Rietjens J.A. van der Heide A. The effects of advance care planning on end-of-life care: a systematic review.Palliat Med. 2014; 28: 1000-1025Crossref PubMed Scopus (630) Google Scholar Furthermore, there are multiple other systemic and organizational factors that may influence the effectiveness of the CPT codes on ACP discussions. Although the introduction of CPT codes to encourage ACP discussions between clinicians and patients represents an important step in recognition and remuneration for ACP, this policy change, and its implications for clinical practice, warrant ongoing scrutiny and systematic study. Public opinion supports direction of financial incentives for ACP to patients over clinicians.12Auriemma C.L. Chen L. Olorunnisola M. et al.Public opinion regarding financial incentives to engage in advance care planning and complete advance directives.Am J Hosp Palliat Care. 2017; 34: 721-728Crossref PubMed Scopus (4) Google Scholar As a profession, we must sensitively acknowledge and mitigate the potential conflict inherent in receiving reimbursement for ACP; the public, and particularly members of underserved populations, may justifiably view this fee structure with skepticism. Because of the sensitivities surrounding ACP, use of these billing codes to augment a clinic’s revenue stream would be particularly egregious and erosive of public trust.