Should Medicare and Medicaid reimburse providers for counseling patients regarding end-of-life issues? Support for Medicare and Medicaid reimbursement for end-of life planning has been growing from a variety of sources, including Congress, state Medicaid programs, the American Medical Association (AMA), the American Academy of Family Physicians, and the Institute for Medicine (IOM). An August 30, 2014, New York Times article, noted that even private payers have begun reimbursing doctors for advance care planning service.
“Currently, the time doctors spend having discussions with their patients about end-of-life care and planning is not reimbursed under Medicaid and Medicare. Without this incentive, these conversations are not happening,” according to a news release issued by Congressman Earl Blumenauer (D-Oregon). On March 14, 2013, Blumenauer and Phil Roe (R- Tennessee) introduced a bill titled “Personalize Your Care Act” (H.R. 1173) that would provide for coverage of voluntary advance care planning consultation under Medicare and Medicaid every 5 years or in the event of a change in health status. In summary, the bill, which had 58 additional co-sponsors, allows for periodic revisiting of advance care documents and goals of care recognizing that an individual’s preference may change over time. It also provides grants to states to establish or expand physician orders for life sustaining treatment programs and improves the accessibility of advance care planning documents by ensuring that an individual’s electronic health record is able to display his or her current advance directive and/or physician orders for life sustaining treatment so that his or her wishes would be more readily known. The bill was endorsed by AARP, American Academy of Hospice and Palliative Medicine, American College of Physicians, American Geriatrics Society, American Hospital Association, and the American Academy of Family Physicians.
Blumenauer along with 33 other members of the House of Representatives sent a letter to Marilyn Tavenner, CMS Administrator, on September 24, 2014, urging CMS to adopt recommendations to reimburse Medicare providers for voluntary discussions with patients on end-of-life care and planning. Blumenauer cited to a recent study in the New England Journal of Medicine that found that more than one in four elderly Americans lacked the capacity to make their own medical care decisions at the end of life.” He noted that this leads to decisions that are made by family members and doctors “who may not know the treatment preferences of their loved one.” To conduct complex and time consuming end-of life discussions regarding patients’ goals and wishes, Blumenauer stressed that providers need adequate time, space, and reimbursement.
AMA Establishes End-of-Life CPT Codes
Blumenauer noted in the letter that the AMA has created two specific current procedural terminology (CPT) codes for providers to report advance care planning services with patients to CMS. He urged Tavenner to adopt the CPT codes recommended by the AMA in the Medicare Physician Payment Schedule so that providers could be reimbursed for end-of life discussions with patients. According to a September 19, 2014, article in Medscape Multispecialty Medical News, the AMA CPT codes, which will be incorporated into the CPT in January 2015, are “a necessary step for Medicare to begin considering reimbursement for end-of-life discussions between physicians and patients” and also “will help streamline reimbursement from private payers.” One of the two codes would be used for the first 30 minutes of face-to-face time with the patient or family member to discuss advance directives and the second code would be used to bill for each additional 30 minutes of planning.
The Medscape article noted that “The Illinois State Medical Society submitted an editorial proposal to the AMA’s CPT Editorial Panel requesting that a code be added for advance care planning services.” In response to the Illinois State Medical Society’s request, the CPT Editorial Panel created the new codes, which then “triggered an evaluation of the time and resources required to perform the services detailed in the code,” according to Medscape. The AMA’s Relative Value Scale Update Committee (RUC), which evaluates time resources and raw materials, “has met to discuss advance care planning services and has submitted its reimbursement recommendation to Medicare,” Medscape said.
IOM’s Report on “End-of-Life”
In its report “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” published in September 2014, the IOM noted that the medical community has more knowledge about how to better engage patients and families in advance care planning and shared end-of-life decision making. The IOM committee recommended “integrated, person-centered, family-oriented, and consistently accessible care near the end-of-life be provided by health care delivery organizations and covered by government and private insurers.” IOM stated that advanced planning is of critical importance to ensure individuals goals and needs are met. Recognizing the usefulness of advance directives, the IOM stressed, nonetheless, that they “should not take the place of open, continuous communication.” IOM recommended payers and health care delivery organizations adopt standards “as a necessary component of high-quality care for individuals with advanced serious illness and their families and enable them to seek these services from their physicians and providers. “