Advance Care Planning Does Not Reduce Health Care Utilization

Although patients who have advance care plans have higher rates of hospice utilization, these plans do not reduce the likelihood that a patient would seek aggressive treatments at the end of life, a new study has found. 

Health care providers and payers are giving increasing attention to advance care planning as a benefit to patients and families as as a pathway to controlling costs. Discussions of end-of-life wishes, a part of the advance care planning process, can help foster earlier hospice enrollment and reduce the stress and confusion that families face when a loved one is dying. However, a recent found that advance care planning does not guarantee lower health care utilization.

The purpose of advance care planning is to document patient wishes for end-of-life care as well as designating proxy decision makers should the patient become unable to communicate. The goal is not to move patients into hospice, but to support the patient’s own preferences, which could include hospitalization or aggressive curative treatment.

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A key component of advance care plans is a Provider Order for Life Sustaining Treatment (POLST) form, as well as documentation of a proxy to make decisions on behalf of the patient should they become unresponsive.

“In a national sample of seriously ill patients with Medicare Advantage insurance coverage, having a billed [advance care planning] encounter was associated with a higher likelihood of hospice enrollment and mortality in the six months after the index visit,” the study’s authors indicated. “Although these patients were also more likely to be hospitalized, including in the [intensive care unit], they were less likely to receive intensive therapies … In addition, patients with [advance care planning] encounters accrued greater total health care costs that were primarily associated with their hospitalizations.”

For the study, researchers reviewed claims data for 18,484 seriously ill patients who are covered through Medicare Advantage, 864 of whom had a billed advance care planning encounter between Oct. 1, 2016 and Nov. 30, 2017. The patients suffered from illnesses ranging from cancer, neurodegenerative conditions, renal disease, fibrotic lung disease and heart failure, among other illnesses. The patients included in the study sample were expected to have two years or less of life remaining.

“Although patients with billed [advance care planning] encounters were more likely to be hospitalized and admitted to the ICU, also possibly because of uncontrolled differences in severity of illness, they were less likely to receive intensive therapies,” the study found. “These seemingly inconsistent results might be reconciled if the care received during hospital stays was different for patients with and without advance care planning claims. For example, seriously ill patients who are hospitalized for symptom management or further clarification of goals of care during an acute deterioration in their health may not receive the intensive therapies that would otherwise be medically indicated.”