Assessment of First-Year Use of Medicare’s Advance Care Planning Billing Codes | End of Life | JAMA Internal Medicine | JAMA Network
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Table 1.  Use of ACP Services Among Medicare Fee-for-Service Beneficiaries in New England in 2016
Use of ACP Services Among Medicare Fee-for-Service Beneficiaries in New England in 2016
Table 2.  Unadjusted and Adjusted OR Estimates of an ACP Claim Among New England Medicare Fee-for-Service Beneficiariesa
Unadjusted and Adjusted OR Estimates of an ACP Claim Among New England Medicare Fee-for-Service Beneficiariesa
1.
Heyland  DK, Barwich  D, Pichora  D,  et al; ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET).  Failure to engage hospitalized elderly patients and their families in advance care planning.  JAMA Intern Med. 2013;173(9):778-787. doi:10.1001/jamainternmed.2013.180PubMedGoogle ScholarCrossref
2.
Tung  EE, North  F.  Advance care planning in the primary care setting: a comparison of attending staff and resident barriers.  Am J Hosp Palliat Care. 2009;26(6):456-463. doi:10.1177/1049909109341871PubMedGoogle ScholarCrossref
3.
Fulmer  T, Escobedo  M, Berman  A, Koren  MJ, Hernández  S, Hult  A.  Physicians’ views on advance care planning and end-of-life care conversations [published online May 23, 2018].  J Am Ger Soc. Google Scholar
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    Research Letter
    March 11, 2019

    Assessment of First-Year Use of Medicare’s Advance Care Planning Billing Codes

    Author Affiliations
    • 1Healthcentric Advisors, Providence, Rhode Island
    • 2Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
    • 3Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
    JAMA Intern Med. 2019;179(6):827-829. doi:10.1001/jamainternmed.2018.8107

    Advance care planning (ACP) conversations occur infrequently among patients and their health care professionals, and when they do occur, the context is often a stressful clinical situation.1,2 Advance care planning conversations that occur too late (or not at all) can result in care that is invasive, expensive, and not aligned with patients’ wishes. To encourage health care professionals to initiate ACP discussions, Medicare began reimbursing for ACP services on January 1, 2016, under a separate billing code. Our study aims to characterize the first year of ACP code use and to describe beneficiary characteristics associated with receipt of ACP services.

    Methods

    For this retrospective observational analysis, we used Medicare fee-for-service Parts A and B claims, the Medicare coverage and denominator files, and US Census Bureau data. All beneficiaries in New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) continuously enrolled in Parts A and B in 2016 were included in this sample. Beneficiaries who died during the study year were included until their death. The authors have access to Medicare claims data under an agreement between Healthcentric Advisors and the Centers for Medicare & Medicaid Services for use of these data to evaluate improvement in care quality. Institutional review board review is not required in these circumstances, per organizational policy.

    Our primary outcome was the number of Medicare fee-for-service beneficiaries with an ACP claim in 2016. Secondary outcomes included beneficiary-level estimates of having a claim and the number of beneficiaries whose ACP service occurred during their annual wellness visit. We used χ2 tests to compare beneficiary characteristics by ACP claim status. Using multivariable logistic regression, we identified variables associated with a beneficiary having any ACP claim, adjusting for age, sex, race/ethnicity, state of residence, dual-eligibility status (for Medicare and Medicaid), median income of residence, and the presence of certain chronic conditions. Findings were considered significant at P < .05 (2-sided).

    Results

    In 2016, 26 522 ACP claims were billed by 1996 health care professionals in New England. These claims occurred among 24 536 unique beneficiaries (Table 1), representing fewer than 1% of the total beneficiaries in New England. Most ACP claims were billed in the office setting (16 755 [63.2%]), followed by nursing home (4671 [17.6%]) and inpatient settings (2671 [10.1%]). A total of 10 622 ACP services (40.0%) occurred during an annual wellness visit.

    Among all 2016 ACP claims, 5014 (18.9%) were billed by advanced practice clinicians and 21 508 (81.1%) by physicians. Most of the physicians were from internal medicine (14 025 [65.2%]), followed by family medicine (4764 [22.1%]) and geriatrics (1111 [5.2%]). Oncology and hematology specialists billed 92 total claims (0.3%).

    Compared with beneficiaries without an ACP claim, greater proportions of those with a claim were female (59.2% with vs 56.1% without), 85 years or older (27.1% vs 12.9%), enrolled in hospice (10.5% vs 2.2%), and classified as deceased during the study year (15.1% vs 4.2%). Fewer beneficiaries with a claim had dual eligibility compared with those without (18.0% vs 24.0%).

    In our fully adjusted model (Table 2), older age (OR for ≥85 years, 0.86; 95% CI, 0.83-0.90), lower income (OR, 1.36; 95% CI, 1.30-1.42), and the presence of certain cancers (OR, 1.52; 95% CI, 1.47-1.58), heart failure (OR, 1.69; 95% CI, 1.64-1.75), stroke (OR, 1.37; 95% CI, 1.31-1.42), chronic kidney disease (OR, 1.91; 95% CI, 1.85-1.97), and dementia (OR, 2.16; 95% CI, 2.09-2.24) were associated with higher odds of having a claim. Being male (OR, 0.63; 95% CI, 0.58-0.68), Asian (OR, 0.84; 95% CI, 0.73-0.96), black (OR, 0.63; 95% CI, 0.58-0.68), and Hispanic (OR, 0.40; 95% CI, 0.34-0.48) and having dual eligibility (OR, 0.73; 95% CI, 0.70-0.75) were associated with lower odds of having a claim.

    Discussion

    Results of this study found limited use of ACP services in 2016 and differences in use among various subgroups, including by race/ethnicity and by dual eligibility status, even after adjustment. Health care professionals may be having ACP conversations and missing out on reimbursement or not discussing these issues with patients at all,3 even those beneficiaries who would likely benefit the most. Our findings can inform interventions to increase awareness and use of ACP services and can encourage strategies for incorporating these codes into clinician workflows. We suggest focusing on the opportunities for increased uptake among physicians caring for dually eligible and nonwhite beneficiaries, among hematologists and oncologists, and during annual wellness visits, when beneficiaries would not be responsible for co-payments.

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    Article Information

    Accepted for Publication: November 26, 2018.

    Corresponding Author: Kimberly Pelland, MPH, Healthcentric Advisors, 235 Promenade St, Ste 500, PO Box 18, Providence, RI 02908 (kpelland@healthcentricadvisors.org).

    Published Online: March 11, 2019. doi:10.1001/jamainternmed.2018.8107

    Author Contributions: Ms Pelland had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Pelland, Morphis, Gardner.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Pelland.

    Critical revision of the manuscript for important intellectual content: Morphis, Harris, Gardner.

    Statistical analysis: Pelland, Morphis, Harris.

    Administrative, technical, or material support: Pelland, Morphis.

    Supervision: Gardner.

    Conflict of Interest Disclosures: None reported.

    Funding /Support: This study was supported by contract HHSM-500-2014-QIN014I (Excellence in Operations and Quality Improvement), sponsored by CMS, an agency of the US Department of Health and Human Services.

    Role of the Funder/Sponsor: The CMS reviewed the manuscript and provided comments but did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and decision to submit the manuscript.

    Disclaimer: The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.

    References
    1.
    Heyland  DK, Barwich  D, Pichora  D,  et al; ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET).  Failure to engage hospitalized elderly patients and their families in advance care planning.  JAMA Intern Med. 2013;173(9):778-787. doi:10.1001/jamainternmed.2013.180PubMedGoogle ScholarCrossref
    2.
    Tung  EE, North  F.  Advance care planning in the primary care setting: a comparison of attending staff and resident barriers.  Am J Hosp Palliat Care. 2009;26(6):456-463. doi:10.1177/1049909109341871PubMedGoogle ScholarCrossref
    3.
    Fulmer  T, Escobedo  M, Berman  A, Koren  MJ, Hernández  S, Hult  A.  Physicians’ views on advance care planning and end-of-life care conversations [published online May 23, 2018].  J Am Ger Soc. Google Scholar
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