Recent federal advance care planning legislation could boost utilization and provide more insights into goal-concordant care at the end of life, though the bill may face opposition due to potential costs.
Last week U.S. Senators Mark R. Warner (D-Va.) and Susan Collins (R-Maine) introduced the Improving Access to Advance Care Planning Act to the Senate designed to promote greater access to those services among Medicare beneficiaries. Similar legislation was introduced in the U.S. House of Representatives by Rep. Earl Blumenauer (D-Ore.)
If enacted, the legislation would remove co-pays and patient fees for advance care planning (ACP) services, allow social workers to conduct these conversations, expand provider education about associated billing codes, and improve reporting on barriers to ACP utilization.
Some data has shown that advance care planning can boost hospice and palliative care utilization, reduce high-acuity care and associated costs, and increase the likelihood that patients will receive goal-concordant care. Yet, societal factors and poor coordination among health care providers can limit its effectiveness and utilization.
“The data are very mixed, but there is a whole evidence base for advance care planning,” Brian Lindberg, senior policy advisor at the Coalition to Transform Advanced Care (C-TAC), told Hospice News. “In the long run, if people get the care they really want up till the end of life, we might see that many people choose less expensive and less invasive care. We just have never been able to get a claim on the savings around that.”
Some components of the bill could help answer some of those questions.For instance, it would require the Medicare Payment Advisory Commission (MedPAC) to research advance care planning rules, practices, and barriers to utilization within the Medicare program and report their findings to Congress.
Aiming for higher utilization, better data and greater equity
A hope for the bill’s supporters is that it will remove some of the barriers that prevent providers from broaching goals of care conversations with patients, according to Mollie Gurian, vice president of home-based and HCBS policy at LeadingAge, which has endorsed the legislation.
Some of these barriers include cost, a lack of training for providers on how to conduct these conversations, and poor awareness or understanding of ACP or end-of-life care options such as hospice.
“The goal of the bill is to think about barriers to advance care planning utilization. We’re trying to make this conversation as easy as possible to have,” Gurian told Hospice News. “One is removing the copay for any potential cost barrier. Another is allowing the definition of eligible providers of these services. A third piece is that it’s a really important education campaign for professionals who can bill for it to know how and when to use it and also be more trained in having these conversations.”
Currently, ACP conversations typically involve a 20% copay for patients, unless they are within the scope of an annual wellness visit. Physicians, physician assistants, other licensed independent practitioners, and clinical nurse specialists can conduct ACP conversations under existing Medicare rules.
By removing the co-pay and widening the scope of professionals who can hold these discussions, proponents of the bill anticipate that ACP could happen sooner and more often among hospice referral sources.
Also, giving providers more clarity on how they should bill for these services could also make them more likely to encourage them.
Successful implementation of the bill’s provisions could alleviate some long-standing pressures that limited patient access, including the ongoing labor shortage, according to Marian Grant, senior regulatory advisor at C-TAC.
“With limited staffing for physicians, having social workers capable of holding these conversations just adds one more role and option to the mix,” Grant told Hospice News. “A busy team might be able to at least allocate somebody to do the discussion. Social workers are probably the most positioned for these kinds of conversations. But up until this bill, they were not able to be reimbursed for them.”
The ACP legislation also could go a long way to breaking down cost barriers related to socioeconomic factors that curb growing awareness among underserved communities, according to Lindberg.
Racial, ethnic, cultural and socioeconomic disparities exist throughout the health care system, including when it comes to advance care planning and hospice care. Racial and socioeconomic disparities also exist when it comes to hospice referrals and quality of care.
Minority groups represented less than 20% of Medicare hospice patients in 2018, with Caucasians accounting for more than 80%, according to the National Hospice and Palliative Care Organization.
“Minority individuals don’t use the annual wellness exam where there’s no copay for ACP as frequently as Caucasians do. So, if minorities do have a serious illness and they’re not in that [wellness] visit, providers may be less apt to offer it if they don’t think that person has resources to pay for it,” Lindberg said. “It’s these situations in which we want to understand the real reasons people don’t have these conversations and figure out how to address this equity issue.”
The ACP bill could help payers pinpoint where, how, and when these discussions are being held across the health care continuum, and ultimately help providers to understand where to best allocate their resources, including staffing and programs aimed at building health equity, he added.
Expanding education among providers through the ACP legislation could hopefully reduce barriers amidst referral streams outside the realm of end-of-life care, added Gurian.
“What’s important to achieving equity is to know what people want and [for them to] have a conversation with a provider that makes them feel heard and that their wishes are going to be listened to,” said Gurian. “A goal of a bill like this and its policies would be to make that happen.”
The question of cost
One potential concern about the bill would be the additional cost to Medicare through removal of the co-pays. This could deter some lawmakers from supporting the legislation, according to Grant.
Sunsetting the co-pays could cost Medicare roughly $104.5 million, Grant told Hospice News. Some stakeholders could see this as “lost revenue” and too high a price tag, she added.
If Congress were to approve the bill and it indeed boosts ACP utilization, Medicare would also be bearing that expense for a higher number of patients, said Lindberg.
However, he added, in the long run these actions have the potential to yield a positive return on investment — if more ACP leads to reduced utilization of high-acuity and facility-based care as a number of its supporters expect.
These are pivotal questions, as one of the most important challenges in modifying any kind of reimbursement in health care is proving the need and that the cost will be worth the value, said Lindberg.
“If Medicare is picking up the individual’s share of the cost, then it can be seen as an added cost to them. But what if we knew that having these conversations could actually save Medicare money?” Lindberg told Hospice News. “That is the dilemma that we face when we try to make changes to entitlement programs. As good as they are, they are not often able to show you the potential savings, or payers don’t even understand what the potential savings will be.”
The ability to connect the dots between the goals of care and the actual care received could be critical to future decisions on how to support aging populations, according to Gurian.
Tracking ACP data across settings could give providers and payers more insight into the full potential of ACP when it comes to health care expenditures and outcomes.
This information could improve understanding of how and where dollars are spent at the end of life and identify cost-saving opportunities, said Lindberg.
As for the bill itself, supporters are optimistic that it could pass with bipartisan support. For now, the bill must meander its way through the legislative gauntlet.
The House version has gone to that chamber’s Ways & Means and Energy & Commerce Committees; whereas the Senate has sent their draft to its Finance Committee.
“We’re optimistic that there may be one or more vehicles that could be used to move the bills this year,” said Lindberg. “Whether that is with these bills or part of another package. The hope that this could be included potentially in any mental health related bill that could move, an end-of-the year package that could move, or any bill that has Medicare in it really, because this is a modification to the Medicare program. We’re at the end of a Congress right now, so if we don’t get this into law this year, they’ll have to introduce the bills again next year and start the whole process with new members of Congress.”