On July 8, following on the heels of the sustainable growth rate repeal, the Centers for Medicare and Medicaid Services released a proposed update to the 2016 Physician Fee Schedule that would reimburse physicians and other qualified providers for conversations with patients and patient families about end-of-life care.
It is yet another move toward higher quality patient-centered care, CMS said in a news release on its website the day the proposed rule change was published. The comment period, which spanned 90 days, closes Nov. 1. The final rule will take effect Jan. 1, 2016.
Although CMS specifically cites the recommendation made by the American Medical Association to make advance care planning a separate, payable service, many physician groups, including the Society of Hospital Medicine, have championed and continue to actively advocate for reimbursement for end-of-life conversations with patients and their families.
“We think that palliative care and hospice services are underutilized, so we support anything we can do to make sure there is more appropriate use of these services,” says Ronald A. Greeno, MD, FCCP, MHM, a founding member of SHM, a longtime SHM Public Policy Committee member, and a current member of its board of directors. “We think it’s important to encourage providers to take the time to have those discussions, and one way is getting reimbursement for that time.”
When CMS considered reimbursement for advance care planning last year but did not propose a rule, SHM wrote a letter in December 2014 to U.S. Department of Health and Human Services (HHS) acting administrator Marilynn Tavenner urging the agency to consider adopting the two codes for complex advance care planning developed by the AMA’s CPT Editorial Panel.1 In May 2015, SHM joined 65 other medical specialty and professional societies in signing a letter to HHS Secretary Sylvia Mathews Burwell asking for these codes to be formalized in CY 2016.2
In the more recent letter, the authors mention peer-reviewed research demonstrating that advance care planning leads to “better care, higher patient and family satisfaction, fewer unwanted hospitalizations and lower rates of caregiver distress, depression and lost productivity.” SHM also cites a 2014 Institute of Medicine report, Dying in America, in which advance care planning is listed as one of five key recommendations.3
Pending final rule adoption, the codes 99487 and 99498 will become payable starting in January 2016.
“We (hospitalists) are in this position pretty much every day, working with people in late life and at the end of life, cycling in and out of the hospital with end-stage chronic diseases,” says Howard Epstein, MD, FHM, CHIE, executive vice president and chief medical officer at PreferredOne Health Plans in Minnesota and a hospice and palliative medicine-certified hospitalist. “I’ll be quite honest: I don’t think reimbursement is going to pay for the time and expertise for these procedures; it’s more offsetting the costs of doing the right thing for patients and families.”
What reimbursement does is lend credibility to the goals of care and advance care planning discussions patients and providers are already having, Dr. Epstein says.
“Having a specific CPT code for this legitimizes it,” he says, “like the field of palliative medicine when it became a board-certified specialty; these kinds of things really matter. They say, ‘This is our procedure.’”
It also enables providers to take the time to have these conversations with patients and families. In a post on the SHM blog in July 2015, Dr. Epstein, also a member of the SHM board of directors, cites a New England Journal of Medicine study indicating that most of the 2.5 million deaths each year in the U.S. are due to progressive health conditions and another that found that a quarter of elderly Americans lack the ability to make critical decisions at the end of life.4,5 The proposed rule, he says, reflects a change in our culture.
“As our society ages, and more and more people go through the experience with loved ones, they are demanding this care,” Dr. Epstein says.
But simply providing reimbursement is not enough, nor should the onus fall squarely on physicians, Dr. Epstein says. Rather, he believes physicians should take advantage of resources provided by SHM, hospital systems, and other organizations that offer training in advance care planning, and all members of a patient care and support team should be well versed in how to have these conversations.
The rule comes just over five years after attempts to include advance care planning in health reform efforts failed, and SHM plans to continue to advocate for national consistency in applying the measure and to work to ensure there are no limits to the timing of advance care planning conversations or where they take place.
“It was just a matter of time. It was bound to happen,” Dr. Greeno says of the rule. “We held out during the discussions of death panels and things like that. There are always lots of political issues with misinformation on both sides. We’ve tried to really communicate how and why we are supportive, and the benefits for our patients and our healthcare system, which is always our goal.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
- Kealey BT. Re: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models and Other Revisions to Part B for CY 2015; Final Rule (CMS-1612-FC). Letter to Administrator Marilyn Tavenner, Centers for Medicare and Medicaid Services, Department of Health and Human Services. December 8, 2014. Accessed September 14, 2015.
- Letter to The Honorable Sylvia Mathews Burwell, Secretary of Health and Human Services. May 12, 2015. Accessed September 14, 2015.
- Institute of Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. September 17, 2014. Accessed September 14, 2015.
- Wolf SM, Berlinger N, Jennings B. Forty years of work on end-of-life care - from patient’s rights to systemic reform. N Engl J Med. 2015;372(7):678-682. doi: 10.1056/NEJMms1410321.
- Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. doi: 10.1056/NEJMsa0907901.