Providers have flooded the CMS with praise for its plan to pay physicians for end-of-life conversations and planning. But many say the proposal should go further.
The proposed policy was outlined amid a variety of policy changes in draft 2016 amendments to the Medicare physician fee schedule. Comments on the payment rule were due this week, and the agency received more than 2,000 of them.
The rule's call for two new billing codes for advance care-planning drew significant attention because providers have long sought specific reimbursement for the conversations and because of the political controversy the matter has stoked in the past. Preliminary attempts among policymakers and lawmakers to address the matter in the Affordable Care Act became mired in the allegation by Sarah Palin and other conservatives that the law would establish “death panels” to restrict care.
The new codes would be used to pay for the time a provider spends discussing patient choices for advance directives and helping them complete forms. One code would cover the first 30 minutes and the other would cover any additional 30-minute blocks that are needed.
The activation of the code “does not mean that Medicare has made a national coverage determination regarding the service,” the agency said in the rule. “Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy.”
And that is part of the problem, say some providers who are already spending plenty of staff time to have these conversations anyway.
The CMS should give clear directives to Medicare Administrative Contractors (MACs) to ensure consistent reimbursement, according to the American Medical Group Association, which represents 435 medical groups that employ nearly 170,000 physicians.
Others say the CMS should just go all the way and create a national coverage decision because some Medicare beneficiaries might benefit from the service.
“This outcome is both inequitable and inappropriate, particularly given the value and widespread need for ACP (advance care planning) services across the country,” the National Association of Community Health Centers says in a comment. The group represents clinics that serve more than 23 million people at more than 9,000 sites throughout the country.
Other providers say there should also be flexibility as to when an end-of-life conversation can take place. The Wisconsin Medical Society, which represents more than 12,800 physicians in the state, says the proposed rule offers little guidance on when Medicare will reimburse the services, other than indicating the services must be reasonable and necessary for the diagnosis or treatment of illness or injury.
“We ask that beneficiaries have access to services before they have had a significant clinical change in their medical condition regardless of their health status,” the group says. “It is important, as it helps make planning part of the routine of care, provides a helpful plan should the person experience an unexpected, sudden, devastating illness or injury, and helps individuals prepare to take on more specific planning when their health condition changes.”
The CMS is also considering making advance care planning “an optional element” of a beneficiary's annual wellness visit.
“We urge CMS to finalize its proposal to pay for ACP services, which is a good step to help ensure that Medicare beneficiaries will be able to develop advanced care plans in conjunction with their medical care providers,” the American Hospital Association said in a comment.
The American Medical Association's CPT Editorial Panel developed the ACP codes, and its Specialty Society Relative Value Scale Update Committee, better known as the RUC, developed values for those codes.
The CMS wrote that it is proposing to adopt the RUC-recommended values beginning Jan. 1, 2016, and would “consider all public comments” it receives.
The proposed fee schedule did not include the RUC-recommended payments for these codes and the CMS emphasized that it was not setting a value at this time.
