Despite New Funding, Few Docs Discuss Advanced Care Planning

Physicians are now reimbursed for end-of-life talks, but most still avoid the conversation. Formal training and systems may go a long way toward making advance care planning not just best practice, but standard practice.

Since Jan. 1, 2016, physicians have been able to bill Medicare for time spent discussing patients' wishes and goals for end-of-life care. Unfortunately, though most physicians say they support advanced planning conversations, most physicians avoid them.  

Despite the silly talk of "death panels" and other empty political controversies surrounding advance-care planning when the Congress was debating the Affordable Care Act, physicians' associations overwhelmingly supported the historic provision in the Centers for Medicare & Medicaid Services (CMS) 2016 final rule allowing payment for these conversations.

As of early spring, however, only 14% of a national sample of physicians who regularly see patients age 65 and older had conducted and billed for these talks, according to a poll jointly released by the John A. Hartford Foundation, the California Health Care Foundation, and the Cambia Foundation. Representatives from the three organizations presented their results during an April 14 webinar.

This research is a rare attempt to quantify physicians', rather than patients', personal motivations and concerns surrounding the issue. "It is a pretty big investment to do a survey of physicians if you want to do it right and with robust methodology which we did," says Tressa Undem, a partner at PerryUndem Research/Communication. "This is not the type of survey you see every day."

'Huge Disconnect'

Tony Back, MD, co-director of the University of Washington's Cambia Palliative Care Center of Excellence and executive director of Vital Talk, says a key takeaway from the study is the "huge disconnect" between the beliefs and actions of the same 736 physicians who said conversations about advance care planning were important (99%) and that it was their responsibility (75%), and not a family member's or another clinician's.

Barriers to end-of-life conversations identified in the study included:

• Lack of time amidst competing priorities
• Disagreements between patients and their families
• Uncertainty about when to broach the subject
• Fear of discomfort
• Concern the conversation would be conflated with giving up

Training Is Paramount

Back said that the results pointed mostly to physicians' reluctance to engage in these challenging conversations.

"Those [barriers], to me, are proxies of lack of skill," he says. "The physician hasn't learned that you can break up the conversation into little chunks… how to deal with families who don't agree… [how to] deal with the issue of whether the time is right, because actually, the time is never right."

These difficulties can be diminished with training, but only 29% of the physicians surveyed have received training. The minority of physicians who've had formal training in advance care planning and end-of-life talks are the ones more likely to conduct them.

Moreover, physicians who report having explicit training in end-of-life conversations are more likely (46%) to find conversations about end-of-life care to be rewarding than those who have not (30%), and also say they feel unsure about what to say in these conversations "rarely or not too often" (60%), compared to those who have not had explicit training (52%).

Physicians who have had such talks with their own doctors also appear to be significantly more comfortable with conducting them, according to the data.

"I think what that means is that even as a physician, you realize more clearly when you've done it yourself that you actually can do it with a patient and it won't be harmful, that you will get through it, and that actually there's some real benefit to it," Back says.

Systematizing the Process

In addition to clinician training—ideally in conjunction with community-level efforts that prime patients to think about their wishes—healthcare systems need to better systemize advance-care planning and the recording of written advance directives, the research suggests.

Specifically, only 3 in 10 respondents (29%) said that their practice or healthcare system has a formal system for assessing patients' end-of-life wishes and goals of care. And when it comes to recording that information, nearly a quarter (24%) said there was no place in their electronic health record (EHR) indicating whether a patient has an advance care plan. Among those who do have a field in their EHR for advance care planning, however, only 54% can access the plan's contents.

Correcting these problems could increase the likelihood of end-of-life conversations.

One good way to trigger the talks, says Back, is through EHR prompts that ask physicians whether they'd be surprised if the patient died within a year. "Those are a group of patients that are at very high risk for having some kind of complication where this conversation would be critically important," he says.

But physicians needn't wait until patients are seriously ill to begin the conversation. In particular, patients should appoint a surrogate decision-maker to whom the medical team can turn if patients can't speak for themselves. "And there's a best practice of having these conversations recorded in the chart in a way that's easily accessible and portable, so that these wishes could be transferred between different institutions," Back says.

The CMS benefit is designed to include these varying circumstances. Specifically, CPT code 99497 covers a discussion of advance directives with the patient, a family member, or surrogate for up to 30 minutes. An additional 30 minutes of discussion takes the add-on code of 99498. These services can be offered and billed as part of Medicare's annual wellness visit.

Medicare will pay a standard amount of $86 for 99497 in a doctor's office and $80 for the service in a hospital, and up to $75 for 99498.

From Best Practice to Standard Practice

A main goal of the research and investments surrounding advance care planning are to make these conversations not just best practice, but standard practice, says Terry Fulmer, RN, president of The John A. Hartford Foundation.

"It wasn't too many years ago when it would be very uncomfortable to ask about organ donations. So think about it if you say to somebody 'If your teenager gets in a car crash can we harvest their organs to save other lives?'" Fulmer says. "How much more sensitive can you get than that? Just like that, where currently we have something on a driver's license… we will get to this because people want it."

Finally, although physicians are well positioned to help this vision become reality, various members of healthcare teams can and likely already contribute to this ongoing dialogue with patients.

As a result, the next phase of research by these three groups will involve focus groups with nurse practitioners, social workers, and others. That work should be underway immediately and results may be available in June.