A new National Poll on Healthy Aging published by the University of Michigan this month found that 59 percent of older adults have discussed advance care planning with family members and/or friends, and nearly one-third of them did so during the first three months of the COVID-19 pandemic.
Advance care planning makes individuals’ wishes and preferences known to health care providers and families ahead of time, which is especially critical when faced with a serious illness.
Although many recently had advance care planning discussions, about one-half of older adults in the poll did not complete legal documentation. The recommended advance care planning documents are a living will and a durable power of attorney for health care, as well as portable medical orders for people with serious illness or advanced frailties – often called Physician Orders for Life Sustaining Treatment or Medical Orders for Life-Sustaining Treatment.
State policymakers interested in promoting good care and avoiding costly and unwanted treatments for people with serious illness can implement strategies that help ensure these tools are used and documented systematically. State strategies, listed below, can help bolster support for advance care planning:
- Provider guidance, licensure, and regulation: States can foster advance care planning by disseminating guidance for providers and adopting practice standards in licensing or payment regulation. Maryland’s hospital licensing regulations outline staffing and other standards for hospitals that include developing an inter-disciplinary care plan for each patient and completing Medical Orders for Life-Sustaining Treatment (MOLST) forms according to state law. New York’s department of health approved the MOLST form to help health care providers discuss and implement a patient’s wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment.
- Reimbursement: State Medicaid programs may reimburse for advance care planning through Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) billing codes. National Academy for State Health Policy (NASHP) research identified a range of codes that could be used by providers to bill for key services, including:
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- End-of-Life Counseling HCPCS (S0257);
- Advanced Care Planning CPT (99497, 99498);
- Home/Community Interdisciplinary Care Team Consult CPT (99341- 99350);
- Inpatient/Outpatient Interdisciplinary Care Team Consult CPT (99366, 99368); and
- Individual, Family, Marriage Counseling, In-Home CPT (99510).
States that use billing codes may want to provide additional guidance to providers on how to use these codes, which are also a helpful tool for tracking the occurrence of these services and supporting best practices. California provided an example of billing codes for advance care planning and related palliative care services in its December 2017 New Policy Guidance for Palliative Care.
- Value-Based Purchasing: Per federal regulations, states must ensure that enrollees of Medicaid managed care plans receive information on how to exercise their right to an advance directive. Some states go beyond this baseline requirement and are using value-based payment to encourage advance care planning. Illinois, as part of that state’s Financial Alignment Demonstration, includes the Healthcare Effectiveness Data and Information Set (HEDIS) Care for Older Adults measure in its Medicaid managed care quality framework. The measure calculates the percentage of enrollees 66 years and older who had four critical services in one measurement year, one of which is advance care planning. Under the demonstration, a percentage of Medicaid managed care organizations’ capitation rate is withheld and then repaid if the managed care organization meets the quality threshold.
- Registries: Several states have or are creating repositories to house POLST forms for patients, so they are readily available to health care providers across care settings when needed. Oregon has a statewide POLST registry, which the state legislature created and funded in 2009. The registry is a public health registry within the Oregon Health Authority and operated through a contract with the Oregon Health and Science University (OHSU) Department of Emergency Medicine. Requests for POLST orders have been the highest ever during the pandemic.
More Information
Funded by a grant from The John A. Hartford Foundation, the National Academy for State Health Planning (NASHP) has been supporting state policymakers across the country in their efforts to improve care for people with serious illness. NASHP has documented policy activity in all 50 states, crafted recommendations to help states advance this care, and has published a series of state policy tools and resources at its Palliative Care Resource Hub.
