Houston geriatrician Hattie Henderson, MD, has always been comfortable discussing difficult topics with her patients, many of whom live in nursing homes or have chronic conditions that require continuous care.
After the COVID-19 pandemic, though, Dr. Henderson says these conversations became more frequent. Her patients began reaching out not just for routine checkups and follow-up appointments, but to discuss something deeper – end-of-life care.
“Many of my patients lost loved ones during the pandemic who had not discussed the care they wanted at the end of their lives with their families or doctors. They learned that if you do not have necessary conversations about your long-term wishes, it is very likely you will not receive the care you desire,” said Dr. Henderson, a member of the Texas Medical Association Council on Science and Public Health and the vice chair of the Texas Health and Human Services’ Palliative Care Interdisciplinary Advisory Council, a statewide advisory committee on palliative care.
According to a December 2019 study by the New England Journal of Medicine, the most common location patients choose to spend their final days of life is in their homes, outpacing in-hospital deaths.
Dr. Henderson says this uptick in home deaths is partly due to advance care planning: patients making future medical decisions after having essential conversations with their physicians in the case they become seriously ill or unable to communicate their health care wishes.
Advance care planning discussions touch on emotional topics like:
• How a patient’s condition can worsen over time when faced with a life-threatening illness;
• Treatment preferences, whether palliative options that alleviate symptoms or more extreme life-sustaining measures like resuscitation or intubation; and
• Who will carry out their wishes when they can’t speak for themselves.
If patients do not discuss these preferences with their care team, many will spend their final days receiving care they did not choose for themselves, such as being transported to a hospital where they “have very little control over their end of life,” Dr. Henderson said.
Fort Worth internist and pediatrician Stuart C. Pickell, MD, says this reality also often leads to increased health care costs. Roughly one-quarter of traditional Medicare spending is for care provided to patients in their last year of life, according to Kaiser Family Foundation research.
Dr. Pickell is a consultant to TMA’s Council on Health Service Organizations, which represents the association in its relationships with organizations and agencies concerned with the problems of aging and long-term care.
Recently, the council helped TMA shape House Bill 3162, which altered elements of the Texas Advance Directives Act, including do-not-resuscitate orders. (See “‘Fighting Our Best,’” page 14.) For years, Dr. Pickell’s independent practice association helped lead the now-disbanded North Texas Respecting Choices program (NTRC) to encourage physicians to discuss patients’ future care preferences through conversations with their families and caregivers.
Through that initiative, Dr. Pickell helped patients choose where they wished to spend the final days of their lives. Care costs for those who either chose to remain at a hospital or were brought there involuntarily often became significant, he says.
Nevertheless, only 37% of Americans have advance directives – legal documents that outline a patient’s preferences for medical care – per July 2017 Health Affairs research.
And although Medicare began to pay physicians for advance care planning eight years ago thanks in part to 2015 advocacy by TMA and the American Medical Association – which Dr. Henderson called a “blessing” – she says it took time to educate physicians on advance care planning and how to receive payment for it.
“Now, we can do the work and get paid for it,” Dr. Henderson said. “It is important we start this conversation as early as we can and educate our patient on how to make their wishes known. All our lives will come to an end at some point. We have to plan for this reality, and we have the tools available to us to do so.”
Hard conversations made easier
Advance care planning is a voluntary, face-to-face conversation between physicians or other qualified health care professionals – including nurse practitioners, physician assistants, and clinical nurse specialists – and their patients, their patients’ family members, caregivers, or surrogates to discuss patients’ health care wishes if they become unable to make their own medical decisions.
Typically, advance care planning is conducted during a Medicare patient’s annual wellness visit. However, according to the American College of Emergency Physicians (ACEP), if a patient is unable to participate in the conversation due to medical illness or lack of capacity, their clinician can discuss their end-of-life plans with an immediate family member or their chosen surrogate, so long as the discussion is face-to-face.
During such conversations, physicians and their patients can discuss and create advance directives for the individual’s health care team and immediate family members to follow during an emergency or possible end-of-life situation.
Physicians can create an advance directive with their patients without an attorney present, according to the Centers for Medicare & Medicaid Services. Physicians also do not necessarily need to be the facilitators of advance care conversation to receive payment for the service.
Physicians also can refer to chaplains, social workers, and others to facilitate a more in-depth conversation following an initial discussion with their patients. Dr. Pickell says that NTRC physicians referred to such professionals when appropriate, then billed for half of advance care services and were paid accordingly by Medicare.
Common advance directives include:
• A living will (or directive to physicians), which is a legal document that tells doctors what common medical treatments or care a patient would want, which ones they would wish to avoid, and under which conditions each of their choices applies;
• A medical power attorney naming which person can make health care decisions for the patient if they are unable to themselves. This person, also known as a health care proxy, representative, surrogate, or agent, should be familiar with the patient’s values and wishes; and
• An out-of-hospital do-not-resuscitate order.
If patients change their mind about an advance directive, they may revoke it at any time, according to TMA Director of Physician Payment Services Carra Benson.
Getting paid
Medicare covers voluntary advance care planning as part of a Medicare patient’s yearly wellness visit. However, commercial plans don’t have to follow Medicare payment rules. TMA staff advises practices to check with private payers directly as they are not required to follow Medicare.
In the past, physicians often didn’t have the resources to help their patients with advance care planning for free.
“These are hard conversations that require a substantial amount of time,” Dr. Henderson said.
Ms. Benson says for physicians to receive payment, they should apply specific CPT codes that cover voluntary conversations about end-of-life care options, both before an illness progresses and during the course of treatment. Clinicians cannot bill for advance care planning conversations of 15 minutes or less and instead should bill a different evaluation and management service, like an office visit for advance care planning discussion of that length. However, two CPT codes cover face-to-face conversations of 16 minutes or more with a physician or qualified health professional, including completing advance directive forms. (See “How to Get Paid for Advance Care Planning,” page 23.)
Additionally, physicians must document advance care planning discussions with the patient and their family member, caregiver, or surrogate (as appropriate) that should include any change in a patient’s health status and health care wishes if he or she becomes unable to make his or her own decision, among other items.
Ms. Benson says physicians can bill Medicare once a year, per patient, unless a change of health status occurs. In that case, physicians can provide and bill for the service as patients’ needs might change.
Additionally, policy and regulatory flexibilities granted during the COVID-19 pandemic still allow physicians to bill for advance care planning conducted via telehealth, per the ACEP.
The power of documentation
Dr. Pickell discusses advance care planning with his patients after talking through future care options. Advance care documents, intended to translate patients’ end-of-life preferences, become part of the patient’s electronic medical record so they can be updated if conditions change, and hospitals and emergency personnel can access them easily.
Patients keep an original form, which travels with them to different care settings, whether a hospital or long-term care facility, for instance. These kinds of documents can be specifically printed on bright pink paper to be easily identifiable to health care workers.
Dr. Henderson says some of her patients have begun to tape printed physician orders or advance directives to the inside of their front doors in case emergency personnel come to their homes, a move that she calls “very, very smart.”
“Under no circumstances do I want my patient’s wishes to go unheard,” she said. “These documents ensure everyone on a patient’s care team respects their wishes.”
NTRC found that patients who had advance care planning discussions had approximately one-third fewer hospitalizations in the last months of life than patients who did not. This led to more “peace” among patients at the end of their life, Dr. Pickell says, and decreased health care costs.
According to Dr. Pickell, these benefits “speak to themselves,” but he says the most important aspect of advance care planning is bringing family members together to understand the patient’s health care wishes.
“Patients assume their loved one will know what care they want during a medical emergency or at critical moments, but that’s not always the case,” Dr. Pickell said. “Having a medical professional there to facilitate the conversation can help guide the patient, because they have the medical knowledge to make the right choices for the patient’s health and well-being.”