A frequent problem among patients who have completed advance care planning is that the provider does not have access to those documents, an expert says.


April 12—Advance care planning (ACP) will be a focus next week as part of National Healthcare Decisions Day. The initiative aims to educate the public and providers about the need for ACP and its eligibility to be billed under Medicare.

About one-third of Americans have advance directives.

A recent case study from the Commonwealth Fund examined the Advanced Illness Management (AIM) program, which aims to support patients as they move from intensive curative treatment to end-of-life care. Developed by Sutter Health, a not-for-profit integrated delivery system in Northern California, AIM uses nurses and social workers to engage terminal patients, elicit and document their goals as their needs evolve, and support them in navigating physical and emotional challenges.

The program places a heavy emphasis on advance care planning to ensure patients’ goals and treatment preferences are elicited as their conditions change, which could mean more or less intensive care at the end of life.

Sutter’s experience with AIM demonstrates the financial benefit of proactively managing care for seriously ill patients and honoring their wishes, according to the case study. After accounting for annual expenses per patient of $2,400-$2,500, the program was found to save payers between $8,000 and $9,000 per person annually. The savings principally came from reduced hospitalizations and emergency department care during the final months—and particularly the final month—of life.

Legal Issues

Legal questions surrounding ACP were discussed in late 2017 during a Kaiser Health News event.

Charles Sabatino, JD, director of the American Bar Association's Commission on Law and Aging, said at the event that a larger proportion of older Americans have ACPs compared with the one-third of the overall population.

Judith Schwarz, RN, PhD, an expert on choices made by patients and families at the end of life, said many healthcare staff don’t have their own advance directives, even as they tell advocates those documents would help them work with their patients.

Schwarz also noted that patients with ACPs need to get “buy-in” on those directives from the nurses and facilities treating them to ensure that their requests are followed.

The lack of immediate availability of advance directives also is a challenge that providers face in caring for terminal patients who cannot communicate their wishes, said Thaddeus Mason Pope, JD, PhD, an expert on end-of-life law. Family members may know that a directive exists, but logistical obstacles may prevent them from getting the document to the providers for review.

Another challenge involves uncertainties about the end-of-life care that healthcare workers are legally required to provide. For instance, a patient’s advance request to stop being fed may be seen as noncompliant with regulations from the Centers for Medicare & Medicaid Services (CMS) and with state elder-abuse laws, said Pope.

“There’s a significant amount of uncertainty, and we know that healthcare clinicians are very, very, very risk averse, and therefore they are generally going to decline to comply” with advance directives to stop feeding patients, Pope said.

Marian Grant, CRNP, DNP, senior regulatory adviser for the Coalition to Transform Advanced Care, said hospitals need to review advance care directives and provide patients with bracelets that indicate a do-not-resuscitate directive.

Mason said plaintiffs are seeing increasing success in suing hospitals that do not honor requests to not resuscitate.

“You’re giving somebody treatment that they did not want,” Mason said.

Monday, April 16

Through April 22, The Conversation Project hosts National Healthcare Decisions Day to educate the public and providers about the importance of advance care planning and its eligibility to be billed to the Medicare Physician Fee Schedule. Learn more.

Through April 19, the Centers for Disease Control and Prevention’s Epidemic Intelligence Service hosts the 67th Annual Epidemic Intelligence Service Conference. Learn more.

Wednesday, April 18

Through April 20, the National Business Group on Health hosts Business Health Agenda 2018. Learn more.

AAMC hosts a webinar on April 18 to discuss ongoing research from the Million Veteran Program (MVP). Learn more.

The Agency for Healthcare Research and Quality hosts a webinar to provide an overview of the Healthcare Cost and Utilization Project databases. Learn more.

CMS hosts a webinar titled “Hospital Inpatient Quality Reporting (IQR) Program CY 2018 Voluntary Reporting: Hybrid Hospital-Wide 30-Day Readmission Measure Overview.” Learn more.

The National Institute for Health Care Management Foundation hosts a webinar titled “Stopping the Superbug Threat: A Growing Imperative.” Learn more.

Altarum’s Center for Value in Health Care hosts a webinar on the ACE Measure, a methodologically validated measure of consumer engagement that can be licensed at no financial cost. Learn more.

Thursday, April 19

An FY19 budget hearing will be held by the House Appropriations Committee’s Subcommittee on Labor, Health and Human Services, Education, and Related Agencies. Learn more.

The Senate Finance Committee will hold a hearing titled “Tackling Opioid and Substance Use Disorders in Medicare, Medicaid, and Human Services Programs.” Learn more.

CMS hosts an Open Door Forum to allow physician, provider, and supplier professional associations to provide feedback on the respiratory-related clinical templates and clinical data elements that are posted on the CMS.gov website. Learn more.

The American Hospital Association hosts a webinar on physician leadership in a value-driven healthcare system. Learn more.

AARP and the Federal Trade Commission host a webinar on new Medicare cards and fraud schemes.  Learn more.

Through April 21, America’s Physician Groups holds its Annual Conference 2018. Learn more.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, April 13, 2018