Advance Care Planning Billing Rules Impede Equitable Access

Current advance care planning reimbursement structures are limiting utilization and access of these services, particularly among communities of color.

The payment barriers blocking more equitable advance care planning are two-fold, existing on both the health care provider and patient sides.

On the patient side, Medicare beneficiaries face out-of-pocket costs when advance care planning is performed in any setting outside of an annual wellness visit. Patients can incur a 20% copay depending on their health care coverage, reported the National Council on Aging.


Facing potential out-of-pocket expenses has led to racial divides in advance care planning utilization among lower income and ethnically diverse groups, according to Dr. Deborah Freeland, assistant professor of internal medicine at UT Southwestern Medical School, Division of Geriatric Medicine, in Texas.

Communities of color are less likely to engage in advance care planning as part of an annual Medicare wellness visit and do so more often in other settings, meaning they often bear those out-of-pocket costs, Freeland stated during the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA) Annual Assembly. The expense can range from $10 to $50 per patient, she added.

“Adding a financial cost further impedes access to an important service,” Freeland said. “This is a health equity issue, with advance care planning cost-sharing disproportionately affecting populations who often lack access to preventive care and adequate financial resources.”


Caucausians make up the bulk of individuals in the United States with advance directives in place, according to research reviewed in Health Affairs. Across 150 different studies, white adults represented nearly two-thirds (65.1%) of roughly 800,000 individuals who had completed advance directives between 2011 and 2016.

On the provider side, limitations in reimbursement for advance care planning has some health care organizations thinking twice before offering these services to patients and having them incur unexpected expenses, Freeland stated.

Data point to this theory as well. Health care providers in another Health Affairs study recently cited code-based constraints to billing, leading to unexpected charges for patients. The study identified this issue as a leading barrier to expanded advance care planning discussions. The 272 participants polled in the 2022 research included clinicians and administrators from 11 health systems nationwide, among other key stakeholders.

Some of the cost constraints are also related to the limited scope of providers eligible to bill for advance care planning services. Currently, this includes only physicians, physician assistants, clinical nurse specialists and nurse practitioners, along with clinical social workers.

“If you spend more than 30 minutes, billable providers are limited to physicians, nurse practitioners and physician assistants. One challenge is that this is not broad enough to include others,” Freeland said. “Numerous advanced care planning tools show that social workers, chaplains and nurses can have those conversations. Inability to bill can really limit access further.”

Some efforts have been made to ameliorate this at the federal level.

The Improving Access to Advance Care Planning Act introduced late last year aimed to expand utilization of advance care planning services by removing Medicare payment barriers faced by both providers and patients. Introduced by U.S. Sen. Susan Collins (R-Maine) and Mark Warner (D-Va.), the bill proposed to remove Medicare beneficiary cost-sharing while also widening the scope of staff who can bill for these services.

However, the bill stalled in committee.

Though this legislation was not enacted, it signals that lawmakers are increasingly recognizing a need for reform that would increase awareness, access and utilization to advance care planning, according to Marian Grant, senior regulatory advisor at the Coalition to Transform Advanced Care (C-TAC).

For example, changes that expanded the eligible billing staff could improve access to these services in underserved communities with lagging clinical resources, she explained.

“A federal bill, in addition to removing cost sharing and doing a couple of other things [like] promoting advanced care planning, was also going to allow licensed clinical social workers to be billable providers,” Grant said during the assembly. “There are places where there are not a lot of physicians, nurse practitioners or physician assistants, but where there might be more people like social workers.”

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