Recent Trends in the Use of Medicare Advance Care Planning Codes

Dear Editor:

Advance Care Planning (ACP) is associated with increased hospice use and palliative care, decreased use of life-sustaining treatments, and greater patient and family satisfaction and peace of mind.^1,2 The emergence of the COVID-19 pandemic, with its associated high mortality rate and potential need to ration scarce resources, has brought ACP to the forefront of public discourse.³ The Centers for Medicare and Medicaid Services (CMS) began payment for ACP services in 2016, but uptake has been slow.⁴ In this report we extend previous evaluations of ACP billing code usage to understand trends in uptake by patients and in the use of codes by providers covering the first three years of the policy change.

Materials and Methods

Using the 20% Fee-For-Service Medicare claims data from 2016–2018, an ACP visit was determined by the presence of codes 99497 (first 30 minutes) or 99498 (extended). We focused on two measures: (1) The ACP use rate was calculated as the number of Medicare beneficiaries with at least one ACP claim divided by all eligible beneficiaries. We measured the cumulative rate for 2016, then for 2016–2017, and finally for 2016–2018, inclusive. (2) The provider claims rate was calculated as the number of ACP claims per provider type per 10,000 claim lines.

The study was approved by the Institutional Review Board at Partners Healthcare.

Results

The cumulative ACP use rate increased from 1.7% in 2016 to 3.8% for 2016–2017, and to 5.9% for 2016–2018 (Table 1). Beneficiaries >85 years old had the highest cumulative use rate (9%) although the most rapid gain was for beneficiaries <65 years old, representing persons eligible due to disability or end-stage renal disease. Although whites had higher rates than blacks in 2016, the gap nearly closed by 2018. ACP rates were higher in urban compared with rural areas, and this disparity has remained fairly consistent.

Table 1.

Cumulative Annual Use Rates of ≥1 Advance Care Planning Visits by Medicare Beneficiary Characteristics, 2016–2018

Characteristic	2016		2016–2017		2016–2018
	No. of eligible beneficiaries	Rate	No. of eligible beneficiaries	Rate	No. of eligible beneficiaries	Rate	Change in rate from 2016 (%)
All	6,460,383	1.7	7,027,342	3.8	7,572,525	5.9	247
Gender
Male	2,949,956	1.6	2,949,956	3.5	2,949,956	5.4	238
Female	3,557,597	1.9	3,557,597	4.1	3,557,597	6.3	232
p-Value		<0.0001		<0.0001		<0.0001
Age
<65	1,120,266	0.8	1,138,575	2	1,215,696	3.2	300
65–74	2,873,947	1.6	3,188,552	3.4	3,496,780	5.1	219
75–84	1,587,234	2.1	1,777,882	4.6	1,963,115	7.2	238
85+	981,979	2.7	1,149,973	5.8	1,303,301	9	237
p-Value		<0.0001		<0.0001		<0.0001
Race
White	5,371,590	1.8	6,097,431	3.8	6,631,817	5.9	228
Black	627,541	1.5	706,351	3.6	771,993	5.8	287
Other	482,815	1.8	549,711	3.9	628,974	5.9	228
p-Value		<0.0001		<0.0001		0.005
Location
Large Central Metro	1,514,506	2.0	1,696,559	4.3	1,880,429	6.7	240
Large Fringe Metro	1,547,576	2.1	172,5045	4.5	1,904,488	6.9	234
Medium Metro	1,497,078	1.6	1,663,771	3.56	1,829,308	5.5	236
Micropolitan	735,552	1.4	804,355	3.0	873,646	4.5	221
Small Metro	793,873	1.7	876,272	3.8	963,302	5.9	247
noncore	443,329	1.1	443,329	2.4	443,329	3.7	251
p-Value		<0.0001		<0.0001		<0.0001
Urban
Urban	5,35,8657	1.9	5,960,347	4.1	6,577,034	6.3	239
Rural	1,174,891	1.3	1,286,746	2.8	1,396,660	4.2	229
p-Value		<0.0001		<0.0001		<0.0001
Region
Midwest	1,477,071	1.0	1,626,031	2.1	1,764,891	3.3	220
Northeast	1,217,127	2.0	1,342,874	4.4	1,471,203	6.8	234
South	2,617,988	2.1	2,920,135	4.5	3,217,041	6.9	234
West	1,220,167	1.7	1,376,704	3.9	1,530,439	6.2	262
Other	15,252.4	0.2	16,453.6	0.6	17,516.9	1.0	326
p-Value		<0.0001		<0.0001		<0.0001

Provider claim rates per 10,000 varied widely by specialty (Table 2). Most ACP visits occurred among generalist primary care providers. Hospice/palliative care providers had the highest cumulative claim rate through 2018 (157/10,000) followed by geriatric medicine (36/10,000); however, acute care use grew the most, increasing by 344% from 2016–2018. By provider role, clinical nurse specialists had the highest ACP claim rate (16/10,000); physician assistants had the largest percentage increase (202%).

Table 2.

Cumulative Annual Claim Rates of Advance Care Planning Visits, by Provider Characteristic, 2016–2018

Characteristic	2016	2016–2017			2016–2018
	Total ACP claims	Rate per 10,000 claim lines	Total ACP claims	Rate per 10,000 claim lines	Total ACP claims	Rate per 10,000 claim lines	Change in claims rate
Specialty
Acute carea	5066	1.2	19,661	3.1	41,319	5.5	344
Generalb	11,4728	7.1	290,768	10.5	522,454	15.1	111
Geriatric	3659	17.7	9016	25.2	15,640	36.3	105
Hospice/palliative	2743	55.6	7796	93.1	15,552	157.4	183
Medical oncology	2499	0.9	7349	1.5	10,896	1.8	112
Surgery	470	0.4	934	0.5	1241	0.5	29
Other	29,287	0.6	85,531	1.0	172,692	1.6	167
p-Value		<0.0001		<0.0001		<0.0001
Role
Clinical nurse specialist	400	6.5	1132	10.2	2267	16.8	158
Physician	136,614	2.3	354,675	3.5	642,368	5.1	123
Nurse practitioner	18,415	5.7	56,104	9.4	115,398	15.2	166
Physician assistant	2321	1.3	7337	2.3	9084	4.0	202
Other	702	0.1	1807	0.1	10,677	0.2	113
p-Value		<0.0001		<0.0001		<0.0001

^aAcute care includes hospitalists and emergency medicine.

^bGeneral includes family medicine, general practice, internal medicine, and internal medicine specialties.

ACP, advance care planning.

Discussion

Although use of ACP billing codes has grown, uptake and spread have been low. Despite gains in ACP among blacks and men in rural areas, older female and white beneficiaries remain the groups most frequently receiving an ACP visit claim.

The COVID-19 pandemic may represent a tipping point to accelerate adoption of ACP. COVID-19 has put a national spotlight on the need to be prepared for unexpected health crises, while allowing rapid innovations in telehealth and expanded ACP billing options that may help to support adoption of this important service.

There are many barriers to integrating ACP into practice, and the use of ACP billing codes is one method to incentivize this behavior. Nevertheless, increased promotion by CMS may be warranted, particularly targeting groups that have traditionally underutilized ACP.

Authors' Contributions

J.S.W. is the principal investigator of the grant and was responsible for conceptualization, guiding analyses, data interpretation, visualization/presentation of the data, writing the original draft/article preparation, critically reviewing and editing the drafts/article preparation, supervision, final approval of the version to be published, and agreement to be accountable for all aspects of the study along with being the corresponding author. P.G. and A.R. were responsible for co-conceptualization, critically reviewing and editing the drafts/article preparation, data interpretation, visualization/presentation of the data, supervision, final approval of the version to be published, and agreement to be accountable for all aspects of the study. J.T. and H.G.P. were responsible for critically reviewing and editing the drafts/article preparation, final approval of the version to be published, and agreement to be accountable for all aspects of the study. D.S. and A.M. were responsible for formal data analysis, critically reviewing and editing the drafts/article preparation, data interpretation, final approval of the version to be published, and agreement to be accountable for all aspects of the study.

Funding Information

This study has been funded by a grant from the National Institutes of Nursing Research (R01 no. NR017034).