Barriers and Facilitators in Advance Care Planning Visits for Medicare Patients: Evidence from National Case Studies
Authors: Ladin K. 
Published: August 2020

Research Objective

In 2016, Medicare began reimbursing clinicians for advance care planning (ACP) discussions to better align patient preferences and care. While meant to encourage ACP, utilization of billing codes remains low for reasons incompletely understood. Our objective was to analyze clinician and system‐level workflow barriers and facilitators related to ACP discussions with Medicare patients, including the uptake of Medicare ACP billing codes.

Study Design

Qualitative case studies, consisting of semi‐structured interviews with key informants, direct observation of organizational structure and clinical workflow, and document review.

Population Studied

Eleven health systems purposively selected by an expert advisory panel to ensure diversity of health system size, region, type (academic, public, nonprofit), and religious affiliation. Within each site, a purposive sample of 25‐30 stakeholders was selected by the local site champion based on role (eg, physicians, nurse practitioners, social workers, billing experts), specialty, and experience with ACP. We interviewed 291 stakeholders.

Principal Findings

Strong leadership and institutional prioritization of ACP encouraged conduct of ACP discussions. This included the following: having a local champion, quality improvement initiatives, training and resources for ACP, and financial incentives for ACP completion. EMR systems that support ACP, such as systematically storing and easily retrieving ACP plans, were under development and recognized as critical. Health systems that perceived ACP as valuable and necessary for promoting safe, quality care more easily justified training and compliance efforts needed to implement ACP.

With respect to billing codes, they were infrequently utilized, even within health systems known for excellence in ACP. Use of codes varied significantly among clinicians even within the same practice. Palliative care clinicians and geriatricians were most aware and likely to utilize the codes compared to others. ACP discussions were very likely to occur more than billing codes reveal, because ACP often may not fit coding constraints.

Clinicians cited documentation burden, time constraints, misalignment of code requirements, and interruption in clinical workflow as barriers to ACP. Lack of knowledge of the codes also posed a significant barrier. Clinicians disagreed about topics such as the appropriate target population, and timing and purpose of ACP, especially among patients not facing acute health care crises. The need for multiple conversations, priming patients, and collaboration with multiple clinicians were other significant barriers.

Conclusions

Efforts to promote and bill for ACP are fragmented, even among institutions and clinicians committed to engagement in these discussions. Revising codes to accommodate repeated conversations and multidisciplinary teams, and consistent storage of ACP documents, may increase utilization and reduce administrative burden.

Implications for Policy or Practice

Findings highlight several policy levers to promote ACP. Development and dissemination of ACP standards and routine monitoring of ACP as mandatory quality measures may accelerate adoption of ACP completion and billing. At the institution level, training for ACP discussions and billing, integrating palliative care into other services (eg, oncology), and a local champion, may improve spread. Finally, more evidence demonstrating that ACP is valuable in promoting patient safety and quality of care is needed to reduce resistance among clinicians and administrators. Taken together, these findings illustrate a comprehensive bundle of recommendations to improve ACP visits overall.

Primary Funding Source

National Institutes of Health.