In its 2014 report, Dying in America, the Institute of Medicine identified several areas for improvement in the care of those with life-limiting illness, including inadequate advance care planning and a lack of payment systems supporting high quality end of life care. Since then, we can point to two notable achievements in support the IOM report’s call for improvement: the proliferation of bundled payment programs and two E&M codes for advance care planning. I believe these developments will make it possible for more patients with serious illness to receive palliative care, as for the first time incentives are aligned between patients’ desires and how care is paid for.
As we learn more about bundled payment programs, it has become clear that the reliable application of basic palliative care principles—like ‘goals of care’ conversations with patients, symptom control, and psychosocial support—is essential to success. Leaders who are setting strategy for healthcare organizations working in bundled payments should prioritize palliative care.
Palliative care skills for physicians and non-physician providersHere I describe two core palliative care skills I believe all physicians, nurse practitioners and physician assistants who care for those with serious illness should possess:
Identify patients who would benefit from palliative care
The ‘surprise’ question (“Would I be surprised if this patient died in the next year?”) has a good ability to predict which patients would benefit from palliative care. In one observation from a group of patients with cancer, a ‘no’ answer identified 60% of patients who died within a year. It has previously been shown to be predictive in other cancer and non-cancer populations. 1,2
Weisman and Meier suggest using the following in a checklist at the time of hospital admission as ‘primary criteria to screen for unmet palliative care needs’ 3:
- The ‘surprise’ question
- Frequent admissions
- Admission prompted by difficult-to-control physical or psychological symptoms
- Complex care requirements
- Decline in function, feeding intolerance, or unintended decline in weight
Hold a ‘goals of care’ meeting
A notable step forward for supporting conversations between physicians and patients occurred on January 1, 2016 when the Centers for Medicare and Medicaid Services announced the Advance Care Planning E&M codes. These are CPT codes 99497 and 99498. They can be used on the same day as other E&M codes and may cover advance planning issues including advance directives, appointing a healthcare proxy or durable power of attorney, discussing a living will, or addressing orders for life sustaining treatment like the role of hydration or future hospitalizations (for more information on how to use them, see CMS FAQs about Billing the Physician Fee Schedule for Advance Care Planning Services 5).
What should physicians concentrate on when having ‘goals of care’ conversations with patient and caregivers? Adriadne Labs, a Harvard-affiliated health innovation group, offers the following as elements of a ‘serious illness conversation’ 6:
- patient understanding of their illness
- patient preferences for information and for family involvement
- personal life goals, fears and anxieties
- tradeoffs they are willing to accept
We know that palliative care improves quality of life for patients while also lowering costs. Here I challenge you to set a goal of incorporating an approach to identifying candidates for palliative care, having regular ‘goals of care’ meetings and rolling out the use of the advance care planning E&M codes in the next 90 days. Your patients (and your bundled payment program) will thank you for it.
- Moss et al. Clin J Am Soc Nephrol 2008;3:1379–1384
- Moss et al. J Palliat Med 2010;13:837– 840
- Weissman DE & Meier DE. J Palliat Med 2011;14:17-23
- Remedy Partners: Analysis of 15,792 patients in Episode Connect between October 2013 and January 2015.
- Center for Medicare and Medicaid Services, Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services, accessed June 24, 2016.
- Ariadne Labs Serious Illness Care Resources, accessed June 24, 2016.