Thursday, December 4, 2014

Medicare (CMS) Reimbursement for Advance Care Planning - Speak Up!

by Phil Rodgers, MD, FAAHPM, Co-Chair, AAHPM Public Policy Committee

(The following is part of a three-post progressive blog about advance care planning, prompted by the Centers for Medicare and Medicaid (CMS) decision not to pay for the new “complex advance care planning” codes in this year's Medicare Physician Fee Schedule. Now is the time to tell CMS why you support reimbursement for these important services! The agency is accepting public comments through Dec. 30 —it’s easy to submit comments online!

Please also see AAHPM Public Policy Committee Co-chair Gregg VandeKieft's update on how key organizations are collaborating beyond AAHPM to make Advance Care Planning efforts succeed. And don't miss out on AAHPM State Policy Issues Working Group Chair Paul Tatum’s GeriPal post where he makes the case that it’s time for advance care planning to become routine for patients with serious illness. - Ed.)

Late on October 31st, the Center for Medicare and Medicaid Services (CMS) published the 1185-page 2015 Medicare Physician Fee Schedule (MPFS). What is the MPFS? If you don’t know, don’t worry—the majority of Americans (including many health care professionals) have no idea this document exists, and until recently I was among them.

In short, the MPFS lays out how Medicare intends to reimburse ‘practitioner’ services for the coming year. ‘Practitioners’ include physicians, nurse practitioners, physician assistants and other professionals who provide ‘qualifying’ services to Medicare beneficiaries. These services are most often described by Current Procedural Terminology (CPT) codes, and valued through Resource-Based Relative Value Units (known as RBRVUs or just RVUs).

I have been fortunate enough to be supported over the past year by the American Academy of Hospice and Palliative Medicine (AAHPM) to serve as their advisor to the AMA’s Relative Value Scale Update Committee or ‘RUC’, which recommends RVU values to CMS for each and every CPT code. In this role, I’ve been able to advocate for the work that HPM professionals do every day, in the process by which those services are described for CMS to determine how much they will pay for them. In other words, HPM has a voice in the process (or ‘seat at the table’, choose your favorite metaphor), in helping CMS understand what it takes to deliver high-quality care for patients with serious illness.

Why should we care? Medicare fee-for-service covers 33 million older and disabled Americans, and in most markets is THE largest payer of hospice and palliative medicine practitioner services. It also often sets payment benchmarks for commercial payers (including Medicare Advantage plans, which cover an additional 14+ million beneficiaries). As a result, the MPFS tells us how and how much HPM practitioners will be paid for a large part of the work they do. So, dense and obtuse as this all may seem, it matters.

The 2015 MPFS matters even more to HPM providers, as it (for the first time) includes Advance Care Planning (ACP) services. These services are described as “…the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; face-to-face with the patient, family member(s), and/or surrogate.” While the descriptor mentions ‘form completion’, these codes really cover more substantive discussions about goals of care, treatment options, values and preferences.

The CPT and RUC processes have developed and valued two codes for these ACP services: 99497 (first 30 minutes, valued at 1.50 RVUs) and 99498 (each additional 30 minutes, valued at 1.40 RVUs). They can be billed in addition to Evaluation and Management (E/M) codes, reflecting the ‘separate and identifiable’ (in CPT lingo) nature of more complex ACP discussions.

The ACP codes have a backstory (see Pam Belluck’s excellent piece in the Aug 30 New York Times) that brushes up against everything from ‘death panels’ to a growing number of commercial insurers and Medicaid programs who have already begun to pay for ACP services. In the 2015 MPFS, CMS acknowledged both codes, but stopped short of authorizing Medicare payment for them for 2015 (more on that below).

I want to pause here to acknowledge two things about these codes. First, it is a major step forward even to describe and value advance care planning services, the enormous impact of which is demonstrated by a growing body of research and the daily work of health care professionals who perform them (including many Pallimed readers). Yes, it’s many years too late and still part of a system of many misaligned financial incentives, but it’s an important start. Second, and more importantly, is that support for ACP services is broad and deep within the physician community. The most striking part of my experience working on these codes has been the coalition that formed to advocate for them.

The American Geriatrics Society − which only received a permanent seat on the RUC in early 2012 ­– has taken the lead to organize this coalition, providing staff support for stakeholder societies (including AAHPM) to join forces and advocate for the ACP codes through the RUC process, and in joint communications and face-to-face meetings with CMS. There are big players involved – like the American College of Physicians and the American Academy of Family Physicians which together represent over 250,000 physicians – along with specialty societies like AMDA – The Society for Post-Acute and Long-Term Care Medicine, the American Academy of Home Care Medicine, the American Academy of Neurology , and the American Thoracic Society. The physician leaders from these groups continue to speak eloquently and passionately about caring for patients with serious illness, and specifically about the necessity of high-quality advance care planning.

Now it’s your turn. While Medicare did not agree to start reimbursing the advance care planning codes for 2015, they did signal openness to reimburse them in the future, and invited comments until December 30. Individual comments really do matter to CMS: staffers read every submission, and individual comments are actually cited throughout the MPFS as rationale for payment decisions.

So, it’s time to tell CMS why you support reimbursement for advance care planning services. You do not need to be a physician or even a clinician to comment . A couple of things to consider when writing your comments:
  • Tell why you think it’s important to pay for ACP services through a specific mechanism. CMS has suggested that it believes Medicare already pays for ACP services through the Evaluation and Management (E/M) and extended service codes.
  • Tell them about the unique value of advance care planning, and how it is ‘separately and identifiably’ necessary in addition to all other services (medical therapy, symptom management, etc.).
  • Be specific, be yourself, and write about what you know. It’s OK to reference the literature about ACP services and palliative care, the IOM report, the importance of tracking the frequency ACP is performed, the needs of an older and sicker society etc., but it’s more powerful to speak from personal experience. 
  • Tell patient stories that illuminate a connection between high quality advance care planning and better care for your patients. Every HPM professional I know has dozens if not hundreds such stories.  

Now is the time to tell them.

Comments are open until December 30 and can be submitted online.

Don't forget to check out the other two blog posts in our progressive blog party! Click the images below.

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