Infrequent Billing for Advance Care Planning Is Ethical Concern

By Stacey Kusterbeck

As a researcher and a primary care physician, Seuli Brill, MD, focuses on how to increase advance care planning in primary care. “Individuals who have the most complex conditions and need advance care planning most may actually be less likely to receive the discussions in primary care settings,” says Brill, an associate professor in the Department of Internal Medicine at Ohio State University College of Medicine.

Lack of time and competing priorities are two major barriers. In primary care, doctors may have just 20 minutes allotted for the visit. “If the patient has complex disease and they are medically decompensating, you are addressing so many things that dedicating a pretty extensive chunk of the clinical visit to advance care planning is not possible,” explains Brill.

Brill and colleagues decided to look at advance care planning for patients with heart failure. “This is a population of individuals who we know, unequivocally, need advance care planning,” says Brill. The researchers analyzed 48,466 Medicaid fee-for-service claims from 2016-2020 at Ohio State University Wexner Medical Center.¹ Of 48,466 patients, only 4,406 had a billed advance care planning encounter.

The study’s findings show that patients with billed advance care planning encounters had decreased expenditures at the end of life. Total end-of-life expenditures were 19% lower for patients with billed advance care planning encounters. The cost savings did not result from patients foregoing care. Rather, patients shifted from inpatient care to the outpatient setting.

“Patients generally prefer to spend their last days at home and not in the hospital. It was encouraging to see that patients still did receive services that they needed,” says Brill. For instance, patients received symptom management, palliative services, and treatment from a comfort care standpoint, all in the outpatient setting. Patients with billed advance care planning encounters were more likely to use outpatient end-of-life services (such as home healthcare and hospice), with 33% higher total outpatient expenditures compared to patients without an advanced care planning encounter. “This suggests that the advance care planning discussion helped patients to be able to access the support they needed in the outpatient setting,” concludes Brill.

One reason advanced care planning encounters are rarely billed by providers is uncertainty over who is supposed to have the discussion with the patient. “The ethical consideration is: Who’s responsible for having this conversation?” says Brill.

Patients with complex conditions, such as heart failure, are under the care of multiple individuals. Usually, the care team includes a primary care physician, various specialists, and inpatient providers. Any of those providers can view documentation of other providers who cared for the patient. “But that doesn’t facilitate a collaborative approach across multiple specialties,” says Brill. “We do this really well in the pediatric environment.”

In the pediatric setting, multidisciplinary providers routinely have case conferences about patients with complex illness. For example, a cerebral palsy patient sees a physical medicine and rehab specialist, a neurologist, and a complex care clinician. If a patient is not doing well, all those providers might have a weekly case conference to discuss what can be done. “In the adult world, there is a lot that can be learned from the pediatric model,” says Brill. Currently, the use of multidisciplinary models for adult patients is more likely to be reserved for rare conditions. Brill says that this approach also is needed for patients with diseases that are very common, such as heart failure. Ideally, team-based conversations are taking place for every patient who had a hospitalization in the past year, to identify which provider is responsible for advance care planning discussion, says Brill.

Brill says health systems can do this by identifying a subpopulation of patients with particular risk factors (such as patients with recurring hospitalizations and patients with early dementia) and creating protocols to specify who does advance care planning for that group of patients. A point person can be tasked with bringing together the team of clinicians who are working with a particular population of patients (such as heart failure patients). The team can establish workflows to identify who is responsible for addressing advance care planning and when. For instance, the protocol might state that whichever clinician had the greatest number of visits with the patient in the previous 12 months is the designated person to address advance care planning.

“There are protocols we use everywhere in medicine. There is no reason why it can’t be done for something like advance care planning in heart failure,” argues Brill.

REFERENCE

1. Bose Brill S, Riley SR, Prater L, et al. Advance care planning (ACP) in Medicare beneficiaries with heart failure. J Gen Intern Med 2024; May 20. doi: 10.1007/s11606-024-08604-1. [Online ahead of print].