By Ryan Van Wert, MD
The Centers for Medicare & Medicaid Services (CMS) has spent many years developing and refining new reimbursement models with the goal of improving quality and containing costs. From the first Pioneer Accountable Care Organization (ACO) model in 2011, to the Next Generation ACO and Medicare Shared Savings Program (MSSP), to MACRA’s Quality Payment Program, we see providers taking on increasing amounts of risk in the shift from fee-for-service to value-based care.
End of life care and advance care planning (ACP) becomes an increasingly important key to success with these risk-based reimbursement models. Consider, for example, that systematic implementation of ACP programs have been associated with a 43% reduction in hospitalizations and can lead to a reduction in ICU admission and length of stay. Five-star patient satisfaction ratings increase from 34% to 51% with ACP discussions. And most importantly, patients get the care that is consistent with their goals and preferences.
The fundamental industry shift toward value-based care is fueling several ACP trends to watch in 2018, including:
1) Demand for palliative services will continue to grow. The number of people aged 65 and older is projected to double between 2000 and 2030 in the United States, and two-thirds of people in this age group will suffer from multiple, chronic illnesses. When you consider this, coupled with the fact that 92% of people would consider palliative care for loved ones with serious disease, we expect demand for ACP to skyrocket over the next 10-15 years.
Hospital-based palliative care programs have grown significantly over the last decade. This is good news, but unfortunately access to palliative care remains inadequate for patients living with serious illness. Community-based programs are more focused on providing palliative care outside of the hospital setting, and can be an effective alternative.
2) Reimbursement for ACP will continue to increase. CMS started reimbursing for voluntary ACP, effective January 1, 2016. Now there are several payers, CMS chief among them, requiring some quantification around ACP. We have not seen ACP become a critical piece to a reimbursement event, but it is more widely recognized as a factor in quality of care.
More than a half-million Medicare beneficiaries took advantage of ACP services in 2016, which almost doubled early projections. In the first half of 2016, CMS made $35 million in ACP payments. As providers in ACO and risk-based models must manage care across the care continuum, we expect ACP services and reimbursements will continue to increase.
3) Quality improvement initiatives will drive more investments in ACP. As incentives shift, healthcare quality initiatives are more likely to support business strategies and services that might cost more upfront, but will result in savings over time. For example, a recent Institute of Medicine report on the quality of end of life care suggests that ACOs have a strong incentive to adopt ACP for long-term success. However one out of five ACOs still have few or no end of life care processes in place, so it remains an opportunity for many of these organizations.
We will see more quality measures that require some quantification of ACP, such as reporting the number of patients asked about end of life decisions and if an advanced directive is on file. The National Committee for Quality Assurance (NCQA), for example, includes ACP in its Healthcare Effectiveness Data and Information Set (HEDIS®) expectations within the Care for Older Adults (COA) measure.
4) State and federal policies will mature. The Coalition to Transform Advanced Illness Care (C-TAC), a nonprofit alliance that advocates for patient-centered policies, continues to break down legislative barriers and introduce new, effective models for advanced illness care delivery.
For example, the coalition has offered recommendations on how best to incorporate advanced illness care best practices into sweeping delivery system reform under MACRA. It is also championing the Patient Choice and Quality Care Act (PCQCA) of 2017 (S. 1334), which allows social workers to bill Medicare for advance care planning services and the Medicare Choices Empowerment and Protection Act of 2017 H.R. 3181, which would give a one-time $75 payment to patients who participate in ACP.
As reimbursement models continue to evolve, we will see more signs of progress with end of life care. Our healthcare system is recognizing the value of ACP in helping patients, their families and communities to achieve better outcomes. We hope that develops into more consistent delivery of ACP in 2018 and beyond.
Ryan Van Wert, MD is the co-founder and Chief Medical Officer of Vynca, part-time Clinical Assistant Professor at Stanford University, and the Assistant Director of the Faculty Fellows Program at the Stanford Byers Center for Biodesign.