“If end-of-life discussions were an experimental drug, the FDA would approve it.”
― Atul Gawande, 2014. Being Mortal: Medicine and What Matters in the End
These conversations are at the philosophical heart of the professions of medicine, nursing, clinical social work, and other health care professions.
Yet the medical profession is mostly ignoring advance care planning/goals of care.
While 82% of adult Californians say they want to express their wishes around their care at the end of life documented in writing, only 23% have done so. A majority of this documentation was facilitated by lawyers as part of estate planning. Only 7% of adult Californians have spoken with a doctor or non-physician clinician about their wishes. (CHCF, 2012: Final Chapter, Californians Attitudes and Experiences with Death and Dying).
When asked, many clinicians will say that they are not reimbursed for these conversations. Although Medicare and Medi-Cal now both specifically reimburse for goals of care/advance care planning conversation, (more on that later), based on this PHC experience, reimbursement is not the key barrier. Partnership Health Plan has had an incentive for such conversations for 8 years, and only 32 clinical sites submitted attestations in 2014-2015.
What is the key to increasing ACP? We can learn from physicians and groups that have been successful in doing ACP for most of their patients. Here is the solution: create processes and systems to integrate ACP with the health care we provide. It sounds so easy, but it is not. Ideally it is a team approach, with each member of the health care team playing a role. The larger community can also play an important role in normalizing these conversations. Underlying it all, though, is a dedication and commitment from the clinicians to make this change. Passionate clinical leadership is key.
Where can you learn more? If you like in-person trainings, the Coalition for Compassionate Care in California (the steward of the California POLST) is working with the Institute of Palliative Care at Cal State San Marcos to put together a training on advance care planning for primary care clinicians. If you are a family physician, the California Academy of Family Physicians is offering Part IV Maintenance of Certification module to use a quality improvement approach to increase advance care planning conversations in your office. You can enroll at www.advancedirectivesMOC.org
About reimbursement: Medi-Cal (including PHC) and Medicare both reimburse for goals of care conversations and advance care planning using the CPT codes: 99497 and 99498. The details of the conversation should be documented in the medical record; see the Medicare regulations for details.
What will happen to the Partnership HealthPlan primary care QIP measure for advance care planning? The measure will continue, but with some changes.
- Effective January 1, 2016, PHC members with dual Medicare and Medi-Cal coverage are no longer eligible for the incentive; Medicare should be billed for the service.
- Effective October 1, 2015, specialists may no longer use the ACP QIP; they should bill PHC for advance care planning using the 99497-8 codes.
- Primary care providers may choose to bill using either 99497-8 OR submit for the PCP QIP, but not both for the same service. In general, physicians in solo and group practices, as well as large medical groups will opt for using the CPT codes. Primary care sites that use the prospective payment system (PPS) will be better off using the PCP QIP, as quality payments are not subject to limits on PPS-rate reconciliation (this includes Federally Qualified Health Centers, Rural Health Centers and Tribal Health Centers).
I will wrap up with a note on high and low quality ACP conversations:
Low quality conversation (without much preamble): “Would you want CPR if your heart stops?”
Another low quality conversation: “You are young and healthy, so I’ll just note that you want everything done,” (without further conversation about what they would want if they had an unexpected neurologic event).
High quality conversation: Start with, “Tell me about your life and what is important to you.”
Another high quality conversation: For patients with advanced illness, here is some additional wisdom from Being Mortal, (a book every clinician should read).
Geriatrician Dr. “Block has a list of questions that she aims to cover with sick patients in the time before decisions have to be made:
- What do they understand their prognosis to be,
- What are their concerns about what lies ahead,
- What kinds of trade-offs are they willing to make,
- How do they want to spend their time if their health worsens,
- Who do they want to make decisions if they can’t?”
Take pride in the profession you chose; talk to your patients about their mortality.
By Robert Moore, MD MPH, Chief Medical Officer