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Policy Avenues for Increasing Access to Advance Care Planning

C-TAC has historically focused on improving access to advance care planning (ACP) as the foundation of person-centered care and it is a key priority for our 2022 policy efforts.

ACP is the process of preparing someone with serious illness for future medical decision making, as opposed to just completing advance directives. Evidence shows that ACP is most successful as an ongoing process done inside integrated health systems or high-trust communities, and that traditional ACP is less accessible to ethnic and racial minorities.

Policy implications

Preparing people for future shared decision making involves changing clinical culture, workflow, training, and public engagement, none of which has been consistently done before nor is easily done via public policy. The current ACP policy levers are reviewed below, and we are also exploring additional ones to advance our goal.

Policy levers

ACP Billing Codes

Analysis of these codes show they are not yet widely in use and, when done outside of an annual wellness visit, carry cost-sharing, which disproportionately affects people from underserved and under-resourced racial and ethnic communities. Last year C-TAC applied to the US Preventive Services Task Force to designate ACP as a preventive service, which would have eliminated the cost-sharing, but it fell outside of their purview. We also asked CMS to remove the ACP cost-sharing via regulation, but they lack the statutory authority to do so. We are now working with Congressional champions on legislation to eliminate the cost sharing as a health equity issue.

Additionally, these codes can only be billed by physicians, nurse practitioners, and physician assistants. (Licensed clinical social workers can bill ACP as “incident to” but only in very limited situations.) We are also pursuing statutory and regulatory changes to expand who can bill these ACP codes.

Telehealth

During the pandemic CMS waived previous telehealth restrictions and allowed a patient’s home as an originating site and the use of audio-only communication, which benefitted ACP. We are advocating to make these changes permanent and support federal legislation to do so.

Quality Metrics

The only confirmed ACP measure is NQF 326 Advance Care Plan. However, this measure puts the focus on the care plan, vs the discussion, and so does not fully capture our latest thinking about ACP. A new measure, Feeling heard and understood, might better address this. C-TAC strongly supports the measure and is advocating for its endorsement by the National Quality Forum (NQF) and use across Medicare and other programs.

Value-based Payment and Team-based Models

C-TAC sees the value of team-based care and recognizes that others on an interdisciplinary team beyond medical providers could do ACP. However, as noted above, the current payment system doesn’t support that. Value-based payment (VBP) typically pays a set amount of money for a person’s care, which can allow a team to deliver that care. Such an arrangement could allow nurses, social workers, chaplains, and other team members to do ACP, as appropriate. C-TAC supports the shift to VBP for this reason and it has been a feature of models we’ve created and advocated for.

Team-based care would also allow for a comprehensive assessment of the person to include social, spiritual, family, and community domains. This is an additional way to identify a person’s priorities so as to better inform their care plan and C-TAC is working with federal and state models to require such comprehensive assessment in future models.

Learn more about C-TAC’s policy and advocacy work or check out our Core Principles for Care Models.

Written by: Marian Grant, C-TAC Senior Regulatory Advisor

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