Pew Urges CMS to Reimburse Providers for Advance Care Planning Discussions

On Dec. 22, The Pew Charitable Trusts submitted comments to the Centers for Medicare & Medicaid Services in support of reimbursement for physicians who discuss advance care planning with seriously ill patients. 

When patients participate in advance care conversations with their health care providers, they are more likely to have their end-of-life wishes known and respected, are more satisfied with their care, and are less likely to receive unwanted medical interventions in the last weeks of life. However, Pew stated in its comments that until physicians’ time for these conversations is reimbursable, patient preferences will continue to be inadequately explored and documented. 

Download the full letter (PDF)

Marilyn Tavenner
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1612-FC
P.O. Box 8013
Baltimore, MD 21244-8013

RE: Establishment of Medicare CPT codes for advance care planning services.

Dear Ms. Tavenner,

Thank you for the opportunity to provide comments on the final rule from the Centers for Medicare and Medicaid Services (CMS) on the establishment of two new billing codes for advance care planning services. Ultimately, these codes—when coupled with adequate Medicare reimbursement—will increase patient access to advanced care planning, which is a critical component of high-quality end-of-life care.

The Pew Charitable Trusts is an independent, non-profit research and public policy organization. Pew seeks to improve the care that Americans receive near the end of life by increasing the use of advance care planning, integrating this planning into care delivery, and evaluating and disseminating innovative models of serving seriously ill patients.

The Institute of Medicine defines advance care planning as the “discussion of end-of-life care, clarification of related values and goals, and embodiment of preferences through written documents and medical orders.”¹ These discussions, which occur between a patient, his doctor, and his family, are a key piece of high-quality end-of-life care. Advance care planning conversations help patients to understand their diagnosis, the health care choices they are likely to face, and potential risks and benefits of different treatment options.

Rigorous research has shown that seriously ill patients derive significant benefits from advance care planning. When patients participate in these conversations with their healthcare providers, they are more likely to have their end-of-life wishes known and respected, are more satisfied with their care, are less likely to receive unwanted medical interventions in the last weeks of life, are less likely to die in the hospital or intensive care unit, and are more likely to receive hospice care.

Unfortunately, numerous studies have demonstrated that even the sickest patients rarely take advantage of advance care planning. For example, a recent study of patients with advanced cancer found that only 27% of patients had discussed end-of-life issues with their oncologist, and only 13% had discussed palliative care with any physician.²

The use of advanced care planning is hampered by the fact that CMS does not reimburse providers for these conversations. CMS can remove this barrier in the Calendar Year 2016 Physician Fee Schedule rulemaking cycle by creating adequate, separate Medicare payment for CPT codes 99497 and 99498.* We strongly urge you to do so. Reimbursement of these services would support greater access to effective, thorough, and ongoing advance care planning among seriously ill patients. In the absence of reimbursement, patient preferences will continue to be inadequately discussed and documented.

A wide range of patient and consumer advocates, clinician organizations, healthcare systems, and policy experts support establishing reimbursement for advance care planning conversations. In its recent report, Dying in America, the Institute of Medicine recommends that public and private insurance programs provide financial incentives for advance care planning.³

Should you have any questions or if we can be of assistance, please contact Josh Rising, director of healthcare programs at The Pew Charitable Trusts, at 202-540-6761 or [email protected].

Sincerely,

Josh Rising, MD
The Pew Charitable Trusts

1. Institute of Medicine, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” (Washington, DC: National Academies Press, 2014), 3-4.
2. Jennifer W. Mack et al., “End-of-Life Discussions Among Patients with Advanced Cancer: A Cohort Study,” Annals of Internal Medicine 153, no. 3 (2012): 4–5, doi: 10.7326/0003-4819-156-3-201202070-00008.
3. Institute of Medicine, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” (Washington, DC: National Academies Press, 2014), S-14.

*  CPT code 99497 is defined as the first 30 minutes of face-to-face advance care planning with the patient, family members(s) and/or surrogate including the explanation and discussion of advance directives such as standard forms and the completion of such forms by the physician or other qualified health professions. Code 99498 refers to each additional 30 minutes of advance care planning.