CMS Urged to Reimburse Providers for End-of-Life Planning

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.

Congressional Support

“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. “

IOM Recommends Communication, Focus on Patient in End-of-Life Care

“Broad improvements to end-of-life care are within reach,” according to a report by the Institute of Medicine (IOM) titled  Dying in America: Improving Quality and Honoring Individual Preferences Hear the End of Life. The report notes that such improvements could enhance the quality of life through the end of life and can help to support a more sustainable health care system.

Person-Centered, Family-Oriented Care

The report notes that transitions between health care settings near the end of life “can fragment the delivery of care and create burdens for patients and families.” Thus, the demand for family caregiving is growing to include not just personal care and household tasks, but also medical and nursing tasks, such as the management of medication. The patients’ comfort is also of the utmost importance, as the study notes that palliative care, which helps aid symptoms, pain, and stress, “is associated with a higher quality of life, including better understanding and communication, access to home care, emotional and spiritual support, well-being and dignity, care at time of death, and lighter symptom burden.” Despite the benefits of palliative care, timely referrals to such care have not been widely adopted.

Clinician-Patient Communication and Care Planning

Patients near the end of life are often unable to make their own decisions about care, and those being given acute care are receiving treatment from physicians with whom they do not have a long-standing relationship. Advance planning helps to take into consideration patients’ values, goals, and preferences. The report states that frequent clinician-patient conversations as to these preferences can “ensure that patient and family decision making is based on adequate information and understanding.

Other Improvements

The report adds that professional education, public engagement, and programs integrating health care and long-term social services have the potential to reduce hospitalizations and costs and improve patients’ quality of life. With the “rapidly increasing number of older Americans with some combination of frailty, physical and cognitive disabilities, chronic illness, and functional limitations,” and due to the cultural diversity becoming more widespread in the U.S., end-of life care can be more responsive and more patient-centered.


Treating Our Wounded Warriors for Mental Health and Traumatic Brain Injuries

The Wounded Warrior Project® (WWP) began some 10 years ago when some fellow veterans and friends took action to provide comfort items at Walter Reed Army Medical Center to wounded service members returning home from Afghanistan and Iraq. Ten years later, with a stated mission to honor and empower our wounded warriors, WWP has grown into a holistic rehabilitative effort to assist wounded warriors recover and transition back to civilian life. Tens of thousands of wounded service members, their family members, and caregivers receive support each year through 19 separate WWP programs.

Some of you may know of the WWP through its national fund raising efforts, such as the Billy Casper Golf’s (BCG) fourth-annual “World’s Largest Golf Outing” – a simultaneous event played at more than 110 BCG-managed golf courses in 28 states on Monday, August 11 – which raised more than $875,000, a record high, for WWP. Over 12,000 golfers, including 439 injured service members, participated in this largest, single-day golf fundraiser in the history of WWP. Former President Bill Clinton, the 2014 recipient of the PGA of America’s Distinguished Service Award, supported the World’s Largest Golf Outing in his suburban New York City community.

Several WWP programs provide assistance for veterans who are suffering with mental health problems or traumatic brain injuries (TBI). They include:

  • Combat Stress Recovery Program addresses mental health needs of injured service members through innovative programming and therapeutic options for the stages of the readjustment process.
  • Project Odyssey® uses the healing power of nature, along with support from mental health professionals and staff, to help wounded service members gain perspective on life through outdoor activities and retreats.
  • Restore Warriors® (org) is a website for warriors and families looking for information and practical advice about living with combat stress and post-traumatic stress disorder (PTSD).
  • The Independence Program offers the opportunity for warriors who have suffered TBI, spinal-cord injury, or other neurological conditions to engage in social, recreational, wellness, education, volunteer, and other activities.
  • Physical Health & Wellness programs serve all Alumni (including those with amputations, spinal cord injuries, burns, visual impairments, TBI, PTSD, and other cognitive or mental health conditions) and are designed to optimize the physical and psychological well-being of Alumni through comprehensive recreation and sports programs, physical rehabilitation, and nutrition programs.

 Mental Health Needs

The WWP has provided testimony at 16 congressional hearings on mental health issues since 2011. As part of its government advocacy efforts, on July 10, 2014, WWP Alumnus Josh Renschler, testified before the House Committee on Veterans Affairs on the VA’s mental health care programs. Renschler, Sergeant U.S. Army (Retired), served as an infantryman for five and half years before being medically retired following a mortar blast in Iraq in 2004, where he sustained severe back injuries and subsequently developed PTSD. Renschler testified that “access” to mental health care alone will not solve the problems facing injured service men and women. According to Renschler, “Access to a system where I go to three different buildings to see three different providers for health issues that are all related to my mental health – pain, lack of sleep, and relationship issues – is a real problem when those providers aren’t working as a team, and aren’t even given the time needed to coordinate their observations and treatment approaches with one another. In other words, access to mental health care isn’t enough unless that mental health care is also effective.”

Renschler also cautioned that proposals to expand veterans’ access to non-VA mental health care provide no “silver bullets,” given a national shortage of mental health care providers. While he believes “there are VA facilities that are providing veterans’ timely access to effective, patient-centered mental health care, that is not the case systemwide. Unfortunately there are no measures in place to assess patient outcomes.”

Renschler’s claim that there are “no measures in place [at the DoD and VA] to assess patient outcomes” is supported by a June 20, 2014 Institutes of Medicine (IOM) Report Brief. The IOM brief notes that between 2004 and 2012, the percentage of all active-duty service members with a diagnosis of PTSD increased from 1 to 5 percent. In 2012, more than half a million veterans of all eras sought care for PTSD through VA health care services—making up 9.2 percent of all VA users. Almost 24 percent of these veterans (119,500) had served in the Afghanistan and Iraq conflicts.

The IOM brief found that neither DoD nor VA has a mechanism for the systematic collection, analysis, and dissemination of data for assessing the quality of PTSD care. The report also found that: (1) many of the DoD and VA PTSD care programs and services are under different commands and authorities, which makes it difficult to identify and evaluate them; (2) neither DoD nor VA is in a position to provide high value care, primarily because of the lack of outcome data, but also due to the absence of cost information for certain treatments; and (3) although the DoD and VA have taken the important first step to increase access to care, the referral process to purchased care providers appears to be ad hoc rather than thoughtful clinical decision making, questions remain about providers’ adherence to the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress, adequacy of training in evidence-based treatments for both direct care and purchased care providers, and the ability of providers to deliver that treatment.

The WWP’s 2013 Annual Alumni Survey further supports the existence of a problem in providing access to and adequate mental health care for our veterans. For example, the survey shows that 75.4 percent of WWP alumni reported having experienced PTSD, but only 55.2 percent of WWP alumni said they had visited a professional to get help. The survey also found that 34.2 percent of WWP alumni said they had difficulty in getting mental health care, put off getting such care, or did not get the care they needed. The reasons reported included inconsistent treatment or lapses in treatment, and feeling uncomfortable with existing resources within the DoD or VA. In fact, only 9.8 percent of WWP alumni reported they have not had any mental health concerns since deployment.

 Traumatic Brain Injuries

On July 29, 2014, after lobbying by WWP, the U.S. Senate and House Committees on VA Affairs included a three-year extension of the VA’s Traumatic Brain Injury (TBI) Assisted Living pilot program in their compromise VA legislation. This extension provides a reprieve for wounded veterans who would have otherwise been evicted from their rehabilitation programs and reopens the program for those who were locked out since February 2014. Specifically, H.R. 4276, the Veterans Traumatic Brain Injury Care Improvement Act of 2014 – amends the National Defense Authorization Act for Fiscal Year 2008 to extend the VA’s Traumatic Brain Injury (TBI) Assisted Living pilot program to assess the effectiveness of providing assistance to eligible veterans with traumatic brain injury to enhance their rehabilitation, quality of life, and community integration.

On August 7, 2014, when President Obama signed into law the $16.3 billion landmark reform of the troubled VA (the Veterans Access, Choice and Accountability Act (H.R. 3230)), it included the provisions of H.R. 4276 in Title V of the Act.

WWP has announced that it is pleased not only with the VA bill’s extension of the TBI Assisted Living Pilot Program, but also the emergency funding for VA staff and facility expansion, and the prospect that “wounded warriors will benefit from a requirement that public colleges and universities limit the tuition costs to post-9/11 GI-bill beneficiaries to in-state tuition rates regardless of the veteran’s state of residence.”

However, while the WWP is pleased with the congressional compromise and passage of the VA overhaul bill, it continues to be concerned that with a “national shortage of primary care physicians and mental health providers, and a culture that allows access issues and cover-ups to fester, the promise of this legislation may not be realized.”

 Other WWP Programs

Fourteen additional WWP programs also focus on engagement of the wounded warrior, the nurturing of his or her mind and body, and encouraging economic empowerment. These WWP programs include:

  • The Alumni program offers assistance, communication, and camaraderie for injured service members through educational sessions, sporting, and social events.
  • Benefits Service provides Alumni and their families with information and access to government benefits and a full range of programs and the community resources necessary for successfully transitioning to life after injury.
  • International Support supports warriors at Germany’s Landstuhl Regional Medical Center (LRMC), the Ramstein Air Base, and those in the Warrior Transition Battalion (WTB) in Europe.
  • WWP Packs contain essential care and comfort items designed to make wounded service members’ hospital or poly-trauma center stay more comfortable.
  • The WWP Resource Center responds to specific internal and external resource requests and proactively reaches out to Alumni and their family members to engage them in available programs and services.
  • Peer Support mentors are trained to be resources and listeners who can share their understanding and perspective with Alumni and their family members.
  • Family Support reaches out to the family members who suddenly find they are serving as full-time supporters or caregivers.
  • Soldier Ride® is an initiative that provides adaptive cycling opportunities across the country to help Alumni restore their physical and emotional well-being.
  • Education Services provides outreach, information, and self-advocacy skills training to Alumni interested in attending or returning to school or who need support while in school. WWP also provides information and resources to help colleges, universities, and vocational programs support, accommodate, and retain student warriors.
  • TRACK™ is the first whole-life approach to education for Alumni. This one-year program focuses on academic and vocational needs, including the ability to earn up to 24 credit hours at a local college, health and wellness training, and individualized performance and goal-setting training.
  • Transition Training Academy™ (TTA) provides the opportunity for WWP Alumni to learn valuable information technology (IT) career skills with future employment opportunities. TTA has perfected a unique, blended learning environment designed expressly for wounded service members, and allows WWP Alumni to explore the IT field as a career.
  • Warriors to Work™ provides career guidance and support services to wounded service members interested in transitioning to the civilian workforce. Warriors to Work specialists assist Alumni with individualized goal setting, building an effective resume, preparing for an interview, networking, access to internships, and assistance with job placement.
  • Policy & Government Affairs provides a voice to the thousands of wounded service members we represent at the Federal level. WWP creates, advocates for, and helps to implement legislation that will maintain wounded service members and their families far into the future and keep them informed about changes in laws and programs that will impact them.
  • Community Integration Grants provide grants to organizations dedicated to honoring and empowering Wounded Warriors. By providing these grants, WWP is able to increase the breadth and scope of programs and services offered to wounded service members while continuing to reach out on a local level.

Little Progress in Reducing Deaths from Preventable Medical Errors

While progress is being made in certain areas of preventable hospital errors, such as dramatic reductions in the rate of central line infections and other hospital associated infections, the overall death rate from preventable medical errors  has not decreased much since the Institutes of Medicine’s (IOM) landmark report, To Err is Human was released nearly 15 years ago. This was the conclusion of a panel of medical experts who testified before the Subcommittee on Primary Health and Aging of the Senate’s Committee on Health, Education, Labor and Pensions at a hearing on July 17, 2014. In fact, the rate may even have increased.

Preventable Errors

Witnesses referred to three studies conducted  from 2011 to 2013 which showed that the number of deaths at hospitals from preventable errors may actually be as high as 400,000 annually, which is significantly higher than the 98,000 annual deaths the IOM report estimated.  The 400,000 number comes from a study conducted by Dr. John James which was published in the Journal of Patient Safety in September of 2013.  Dr. James testified that he got to that number from some pretty simple math. “There were 34 million hospitalizations in 2007, of which approximately 0.9% involved lethal adverse events, and of those approximately 69 percent on average were judged to be preventable,” said Dr. James during his testimony.  He concluded that this leads to 210,000 deaths from preventable medical errors. When he corrected for the missed deaths from medical errors that current tools do not catch, the number came out to be something more like 400,000 lives which “are shortened by preventable adverse event each year,” he stated.

HHS’ Office of the Inspector General estimated that medical errors caused the deaths of nearly 180,000 deaths to Medicare beneficiaries each year in a November 2011 report based on 2008 data, according to Dr. Ashish K. Jha who is also a professor of Health Policy and Management at the Harvard School of Public Health.  Again that number is significantly higher than the 98,000 estimated by the IOM.  Finally a New England Journal of Medicine study of hospitals in North Carolina “showed that there had been little evidence that harm had decreased substantially over the 6-year period,” according to the testimony of Lisa McGiffert, Director of Patient Safety for Consumers Union.


Among the recommendations to reduce this number was better reporting of medical errors, transparency of that reporting to the public and the use of software to go through electronic medical records to uncover medical errors.  All of the witnesses provided anecdotal evidence of medical errors that lead to death, but would not be reported using existing  reporting requirements and software.

One recommendation made by Dr. James and Lisa McGiffert was the establishment of a National Patient Safety Board similar to the National Transportation Safety Board.  The National Patient Safety Board would track the many fragmented safety programs and provide a comprehensive coordinated approach to reducing the number of medical errors, said McGiffert.

Transparency and the public availability of safety data was a recommendation made by Dr. James. He stated that patients have a right to know the safety record of their physicians and facilities where they receive care such as outpatient clinics and nursing homes as well as hospitals.   Dr. Jha recommended more mining of electronic health records to obtain evidence of medical errors. He pointed out that software currently exists that uses data in medical records to identify when a medical error occurred.  Dr. Jha advocated requiring the use of these tools for automated patient safety monitoring  as a part of the meaningful use requirements predicting that it would have a dramatic effect on the reporting of the number of medical errors.

These recommendations were advocated by the witnesses because each related a story of a person  who died as a result of a medical error in a hospital that would never have been reported as a medical error under the current reporting mechanisms.  Dr. James became an advocate of patient safety after his son died due to a medical error.  Dr. James discovered the error by examining his son’s medical records and saw that another physician missed prescribing an essential medication. Dr. James’ point though was that with the current reporting requirements, the failure of one of his son’s doctors to prescribe a medication would not have been reported as a medical error, even though an examination of the medical record indicated it was.