From a recent study:
We analyzed advance care planning (ACP) billing for adults aged 65 years or above and who were managed by a large national physician practice that employs acute care providers in hospital medicine, emergency medicine and critical care between January 1, 2017 and March 31, 2017. Prompting hospitalists to answer the validated “surprise question” (SQ; “Would you be surprised if the patient died in the next year?”) for inpatient admissions served to prime hospitalists and triggered an icon next to the patient’s name. Among 113,621 hospital-based encounters, only 6,146 (5.4%) involved a billed ACP conversation: 8.3% among SQ-prompted who answered “no” and 4.1% SQ-prompted who answered “yes” (for non-SQ prompted cases, the fraction was 3.5%; P less than .0001). ACP conversations were associated with a comfort-focused care trajectory. Low ACP rates among even those with high hospitalist-predicted mortality risk underscore the need for quality improvement interventions to increase hospital-based ACP.
The last sentence
is a non sequitur. The codes are an unreliable measure because many,
I would wager most, ACP discussions are not billed with these
particular codes. Many hospitalists don’t even know they exist.
The codes, 99497 and 99498, were
not even included in the fee schedule until 2016
so they were brand new at the time of the
study.
Ten
years ago similar codes were proposed under the Affordable
Care Act but spurred fierce debate around “death panel” fears.
Those provisions were
dropped before final passage of the law. What’s interesting
is how these provisions were slipped in out of most people’s
awareness, with no public debate to speak of, seven years later.
Political winds change and people are easily distracted.
Only
the American Association of Physicians and Surgeons, (AAPS), a
relatively minor
player in the larger physician community, seemed to mind.
They argued that the
codes, which pay more than ordinary CPT codes, would
incentivize doctors to talk
patients out of life prolonging treatments. That’s an
oversimplification, of course, because some ACP conversations produce
decisions for more care,
not less. That said, the intent of
the measure is to reward
doctors for giving less care toward the end of life. It creates the perception of a conflict of interest though based on the
data above the measure has had minimal impact.
The
public debate about the proposal in 2009 was confused. The idea of
the “death panel” (merely an inflammatory term for an advance
care discussion) was nothing new. We
had been having those discussions for decades. Moreover, the
pre-existing ordinary CPT codes already rewarded doctors for long
discussions through the provision that a higher level of service
could be coded if greater than half the encounter time was spent in
counseling or care coordination. Nobody on either side of the debate
seemed aware of those
facts.
