Uptake and Trends in the Use of Medicare Advance Care Planning Visits
Authors: Gazarian P. 
Published: August 2020

Research Objective

Recognizing that advance care planning (ACP) supports alignment of end‐of‐life care with an individual’s preferences and is associated with improved patient outcomes, and Medicare initiated billing codes for ACP in 2016. Adoption of the ACP codes during the first year has been low. In order to inform Medicare on opportunities to promote the use of the program, we now examine Year 2 trends in uptake by patient and provider characteristics.

Study Design

ACP claims in 2016‐7 were identified by CPT codes. We examined (a) the total annual number of claims; (b) beneficiary ACP use (number and rate of Medicare beneficiaries having one or more ACP visits, annually and cumulative over 2 years); (c) provider ACP claim rate (ACP claims per 10,000 total claims); and (d) spread (increase in total number of unique billing providers by NPI).

Population Studied

348 190 ACP claims from a 20% random sample of fee‐for‐service (FFS) Medicare beneficiaries continuously enrolled from 2016 to 2017.

Principal Findings

The number of ACP claims increased from 137 079 in 2016 to 348,190 in 2017, an increase of 154%.

ACP Use Rates

The cumulative beneficiary ACP use rate increased from 2.12% in 2016 to 3.28% in 2017. Persons over the age of 85 had the highest ACP cumulative use rate (6.15%) in 2017 and the highest percent annual increase in number of users (160%). Whites had the highest ACP cumulative use rate (3.92%); however, blacks had the highest percent annual increase in number of users (176%). Females had the highest ACP cumulative use rate (4.20%); however, males had a slightly higher percent annual increase in users (155%).

Provider ACP Claim Rates per 10,000: Among specialties, hospice and palliative care providers had the highest ACP cumulative claim rate (93.16) in 2017, although acute care specialists had the largest percent increase (243%). By provider role, Clinical Nurse Specialists had the highest ACP claim rate (10.16), although Physician Assistants had the largest percent increase (188%.) The majority of claims (87.2%) were in urban areas, although small metropolitan areas saw the largest percent increase 161%.

In terms of spread, the total number of unique billing providers increased from 14,207 in 2016 to 26,434 in 2017, an increase of 86%.

Conclusions

The use of ACP codes continues to increase; however, the increase in uptake and spread among providers is still quite low. Despite larger gains among Blacks and men, older female and white beneficiaries remain the group most frequently receiving an ACP visit claim. The use of the ACP billing codes has spread to new clinician specialties and provider roles and to small metropolitan areas.

Implications for Policy or Practice

There are many barriers to integrating ACP into practice, and the use of ACP billing codes is one method to incentivize the behavior. Despite the growing use of ACP codes, the slow uptake is notable. The use of ACP billing codes is underutilized, and increased promotion by CMS may be warranted, particularly targeting younger, male patients and more clinical specialties in rural areas.

Primary Funding Source

National Institutes of Health.