Healthcare’s goal is to cure. However, Advance Care Planning (ACP), or end-of-life planning, can address the tension between care at all costs and ensuring an individual’s wishes are met when they can’t speak for themselves.
Research shows that people would prefer certain treatments near the end of their lives over those they often receive. This disconnect can lead to burdensome and costly treatments that may increase suffering.
While 25% of all Medicare spending occurs during patients’ last years, research shows that about 70% of adults prefer less aggressive treatments at the end of life.
Observational studies have highlighted the many benefits of ACP. For instance, patients are less likely to die in the hospital, and they are more likely to receive care that is consistent with their preferences.
More than 50% of Americans know the type of medical treatment they want to receive at their end of life, yet only about 22% have formally documented their wishes. Only 17% of patients say they’ve talked about it with their doctor.
In a value-based care arrangement, ACP can serve four objectives:
- Preserve a patient’s wishes and preferences
- Empower physicians to make confident, patient-driven decisions and recommendations
- Save cost on care that is misaligned with the patient’s desires
- Reduce malpractice risk, family ill-will, and miscommunication
Advance Care Planning brings clarity to patients, families, and providers
ACP helps patients prepare for future medical decision-making in case they are seriously ill or unable to communicate their preferences.
Specifically, ACP includes two primary documents: a living will and a durable healthcare power of attorney.
A living will outlines specific desires regarding the use of life-sustaining therapies and other medical treatments in the event of incapacity or terminal illness. The durable healthcare power of attorney assigns a surrogate or proxy who can make treatment decisions on behalf of the patient.
Today, there are standardized definitions for what is included in ACP. These five components are:
- Goal-concordant care
- Surrogate designation
- Surrogate documentation
- Discussions with surrogates
- Documentation of wishes
As Jen Brull, MD, FAAFP, published in Family Practice Management, “Ultimately, Advance Care Planning is designed to clarify the patient's questions, fears and values, and thus improve the patient's well-being by reducing the frequency and magnitude of overtreatment and undertreatment as defined by the patient.”
As part of ACP, a patient may require specific orders recorded in their living will and in their outpatient and inpatient medical record, including:
- Do not resuscitate (DNR) or allow natural death (AND)
- Do not intubate (DNI)
- Do not hospitalize (DNH)
- Out-of-hospital DNR
- Physician orders for life-sustaining treatment (POLST) or Medical orders for life-sustaining treatment (MOLST)
The importance of Advance Care Planning can’t be overstated. While patients or their families might shy away from the topic, it’s always too early until it’s too late.
Without advance directives or a designated proxy, state laws would determine who may make medical decisions for a patient. This typically implies a spouse, parents, or adult children.
However, authorities may assign a physician to represent the patient’s best interests if no one has been designated.
Who’s participating in ACP and who’s not
In a study conducted at five US teaching hospitals caring for more than 9,000 people, investigators discovered that 49% of patients did not have “Do not resuscitate” (DNR) orders, even though their wish was to not receive CPR.
Of the one-third of patients who preferred that CPR be withheld, fewer than 50% of physicians were aware of their patients' preferences.
For those patients who died during the observational phase, 46% received mechanical ventilation within three days of death, and 38% spent at least 10 days in an intensive care unit.
Nearly 50% of conscious patients who died in the hospital reported moderate to severe pain at least 50% of their time in the ICU.
A review of 150 studies found that only 36.7% of adults had completed an advance directive and 29.3% of those included living wills. Slightly more than 38% of patients living with chronic illnesses had completed advance directives.
While these numbers are quite low, they are high compared to ACP completion rates for different patient populations based on ethnicity.
One survey highlights the differences in Advance Care Planning by race. White patients had statistically higher rates of advance directives documented in their care records compared to patients from other ethnic groups. These numbers include:
- 7% of Asian Americans
- 25% of Caucasians
- 22% of Blacks
- 21% of Hispanics
That same survey found that most Americans believe ACP should begin in their 50s. However, people of color are more likely to indicate that planning should start in their 30s or 40s.
ACP’s importance to value-based care and Chronic Care Management
ACP can be an integral component of value-based care. The process can place further emphasis on person-centric, high-quality, and cost-effective care.
Using Medicare claims and enrollment data from 2015 to 2019, value-based care models, such as Accountable Care Organizations (ACOs), administered ACP at higher rates among fee-for-service (FFS) beneficiaries and at higher rates than Medicare Advantage beneficiaries.
Beneficiaries designated to an ACO were 1.8 times more likely to utilize advance care directives.
Rightsizing care
If patients receive additional therapies that are misaligned with their values and preferences, that care is an unnecessary cost. Engaging in ACP enables clinicians to create more cost-efficient and effective care while ensuring patients receive interventions that match their documented desires.
Results of a three-year study demonstrated $13,916 in reduced costs per patient over an average of 14 months for those who had completed ACP.
Advance planning has been shown to reduce hospitalizations by 26%. One study showed that patients with advance directives had 24.5% lower costs and reduced ICU stays than patients who hadn’t participated in ACP.
Research shows that when providers engage in ACP with patients with the highest one-year mortality risk, monthly healthcare costs can drop by nearly $1,000. Patients who have advance directives also pursue fewer services and less aggressive treatments. They frequently report more satisfaction with their care.
Advance Care Planning CPT codes
Since 2016, Medicare has reimbursed physicians for ACP counseling. The service can be billed using CPT code 99497 for the first 16 to 30 minutes and 99498 for each additional 16 to 30 minutes.
When ACP conversations are incorporated into an Annual Wellness Visit, Medicare reimburses between $80-90 per patient per visit, and patients don’t pay any additional co-pay.
ACP integrates into existing care programs
Under value-based care, with the use of programs such as Chronic Care Management or Transitional Care Management, Advance Care Planning provides opportunities to have timely conversations early and regularly.
While every adult, independent of age or health, should have ACP documents and proxy designations, providers should first focus on patients with one or more chronic illnesses, serious or life-limiting conditions, or those who have a higher one-year mortality risk.
The Annual Wellness Visit presents an excellent time to introduce the concept of ACP, provide educational materials, and broach the subject. Chronic Care Management sessions provide regular opportunities to introduce concepts and educate about the value of ACP, as well as inquire as to any updates to desires or proxy designations.
When a patient is enrolled in Transitional Care Management, it is timely to pursue ACP as the patient’s recent hospital experience or health risks may establish new priorities.
Ultimately, advance care planning conversations have been shown to increase a patient’s satisfaction with their quality of care, resulting in shared decision-making and better preparation.
ACP conversation preparation for clinicians
Physicians are trained in how to diagnose, treat, and hopefully cure. They receive little, if any, training in conversations around end-of-life decision planning.
However, the research portends that patients want to have their physician initiate ACP-related conversations. Here are three resources to help prepare before integrating ACP into the clinical workflow:
- Serious Illness Conversation Guide for Clinicians
- The Centers for Medicare & Medicaid Services and the Medicare Learning Network: Advance Care Planning Fact Sheet
- Journal of General Internal Medicine: A Physician's Guide to Talking About End-of-Life Care
As shown in the research, ACP supports more efficient, patient-centered, and cost-effective care, which is the main objective of value-based care management programs
How ThoroughCare can help
ThoroughCare helps providers coordinate care in collaboration with patients. Our platform includes specialized tools for end-to-end advance care planning.
ThoroughCare enables:
- Providers to engage patients in ACP conversations, including during an Annual Wellness Visit
- Complete documentation of end-of-life care wishes that are legally binding in all 50 states
- A video living will
- Easy access to care plan documents across care team members, the patient, and the patient’s family or power of attorney
- Educational content to fully inform the patient of what ACP entails and how it can benefit them.
Additionally, ThoroughCare supports comprehensive integration with leading EHRs, health information exchanges, and remote devices to coordinate care across preventive health programs. 