Pandemic Spurred Advance Care Planning

In the wake of the COVID-19 pandemic, more patients and families are starting to consider their end-of-life wishes. That trend along with regulatory initiatives are driving movement at a federal level to improve access to these services. Chaplains could be key for hospices to fill in gaps across the health care system and move goals of care conversations further upstream.

Movement at a federal level may soon be promoting advance care planning nationwide. Introduced at the close of 2020, the Compassionate Care Act would significantly expand federal resources to support advance care planning and end-of-life care decision making.

Additionally, waivers released by the U.S. Centers for Medicare & Medicaid Services (CMS) during the public health emergency allowed for audio-only advance care planning (ACP) conversations to be billable through Medicare.


Policies to advance care planning should be integrated into every reimbursement program that touches the lives of the person with serious illness and their family, according to advocates recently speaking at the Coalition to Transform Advanced Care (C-TAC) National Summit on Advanced Illness Care Summit.

“The intersection of advance care planning policy and practice [is one] in which we hope to strengthen the case for continued change and have open discussion regarding policy intent, implementation and practice,” said Stephanie Anderson, registered nurse and executive director of C-TAC’s Respecting Choices program. “CMS reimbursement for advanced care planning through billing codes seemed like a good idea. However, it lacked descriptors and lacked standards, and may or may not have met desired outcomes.”

The COVID-19 pandemic has claimed nearly 763,000 lives across the country since its onset, according to recent data from the U.S. Centers for Disease Control and Prevention (CDC), bringing rising public attention to the need for these conversations.


Advance care planning discussions have been on the rise in the United States during the pandemic, according to research from the JAMA Network. The number of advance care planning users rose to a monthly average of 154 between Jan. 2019 and April 2020. Prior to the pandemic, the median rate was 31 per month.

The JAMA Network researchers also indicated “considerable increases” in advance care planning utilization from Feb. to March last year, a total of 482 users during that period. The individuals indicated they were in better health and younger than most patients who seek an advance care plan. They’re average age was 49-years-old versus 52 pre-COVID, according to researchers.

The study indicated that COVID-19 may be a leading cause of increased demand for advance care planning discussions and documentation, citing reasons such as patients having new motivation and calls for clinicians to promote ACP.

Barriers in current public policy limit the growth of advance care planning services, including unclear billing standards, according to Anderson.

“Just tracking the volume of [advance care planning] conversations does not equate to success,” said Anderson. “So many of these conversations are happening with chaplains and other spiritual care providers in the community, [but] there is no current billing structure in place [and] so there’s extra hoops to jump over.”

Systems could be designed from the payer perspective that drive quality of care and advanced care planning, according to Emily Jaffe, M.D., vice president and executive medical director at HM Home and Community Services, a subsidiary of Highmark Health in Pennsylvania. Jaffe reported that overall the billing rate for advance care planning remains “very, very low” among providers, drawing a response to change in incentive programs.

“The providers that we partner with as a payer were saying that we were incentivizing for the wrong things, and they were correct,” said Jaffe. “We really made some big changes in our incentive program, because a good, developed program should be able to know what the member needs without us saying it has to be this discipline or that one.”

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