How Advanced Care Discussions Impact Provider Payment Focus
By - Critical end-of-life discussions between a physician, a patient, and a patient’s family or loved ones, are perhaps being glossed over more and more because of reimbursement challenges.
The Centers for Medicare & Medicaid Services (CMS) recently proposed a series of changes to the physician payment system under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
But Medicare payment rules may be making it increasingly difficult for patients without hospice eligibility to access community-based palliative care.
“The need for palliative care — the comprehensive care and management of the physical, psychological, emotional, and spiritual needs of patients with chronic, debilitating, or life-threatening illness and their families — is growing rapidly,” said Lee Goldberg, Director of the Improving End-of-Life Care Project at The Pew Charitable Trusts, in response to CMS’s planned amendments.
“Since Medicare regulations only allow prescribing providers to bill for services in an outpatient setting, it is therefore difficult for community-based organizations and small practices to provide the full interdisciplinary team that is a key component of palliative care.”
Christopher Comfort, MD, Calvary Hospital’s Medical Director, recently chatted with RevCycleIntelligence.com about what healthcare providers should consider regarding CMS’s proposal for end-of-life Medicare reimbursement.
The following is the first of a two-part interview.
RevCycleIntelligence.com: As an overview, what are we looking at here in terms of changes to the payment system, Medicare initiatives, and billing discussions?
Christopher Comfort: The concept of hospice is a payment system for Medicare beneficiaries that exists outside the traditional payment system under a typical Part A, Part B, or managed Medicare benefit.
When you're 65 years old and healthy, it may not make sense to have a discussion about advanced care planning. The appropriate time for that discussion may be when you develop congestive heart failure from diabetes at age 75.
Medicare was lobbied heavily by medical and lay organizations with the concept that advanced directive discussion is appropriate when it is appropriate to the patient's condition.
The real purpose was to promote discussion in the outpatient arena so it allows for a separate payment system and for voluntary participation of the patient in that discussion, initiated either by the patient or the physician.
Payment for that occurs either at an annual wellness visit where that will be included in the visit without a financial responsibility for a copay for the patient, or during a visit which does not occur in the construct of the annual wellness visit.
This will be a discussion requiring copayment by the patient. There is also not going to initially be a restriction on the number of times a year the discussion can be billed.
RevCycleIntelligence.com: How might matters of payment agreement unfold during CMS's observation period next year? What's the overarching Medicare perspective?
CC: Medicare is not looking at this as a national benefit. They are not saying it has to be paid for no matter what. They're allowing fiscal intermediaries to make local or regional determinations for payment.
We may see certain regions of the country will pay for these discussions but certain parts of the country may not have intermediaries agreeing to pay. This will require the intermediary to file a local determination to indicate that intermediary will not be paying for this benefit, at least within that geographic region.
The observation period over this first year is going to address all of those issues. They'll look at the frequency of the advanced directive discussions. They’ll look at whether those discussions are occurring during annual wellness visits versus intermittently spaced throughout the care of the patient for the year.
It will allow Medicare to determine whether or not there's a benefit to these discussions and if they should make this a national mandate for coverage of this benefit.
This moves the discussion of advanced directives and advanced care planning out of the realm of the hospital. It hopefully moves palliative intervention upstream so discussions are occurring in a meaningful way for patients and families in a comfortable, noncrisis environment.
RevCycleIntelligence.com: To what extent will payment systems like this help promote industry advancement? What's the greater focus moving forward?
CC: I'm hoping payment systems like this will foster these conversations. I'm hoping the federal government does not look at utilization data of the CPT code and say, "There are four episodes of billing for advanced care discussions in the last year with this same patient. What is this doctor doing?"
For me, that doctor is providing excellent care. He's not overutilizing a CPT code because he understands the dynamic and nuances of the doctor/patient relationship and how important it is for patients to have complete understanding of information given to them.
This is about promoting active participation of patients and families in understanding the resources available for care, the benefits of that care, the risks associated with agreeing to that care, and what other alternatives are available if a patient or family decides against that care.
