We are excited about the introduction of HR 8840/S4873 Improve Access to Advance Care Planning Act. We applaud Rep. Blumenauer, Sen. Collins, Sen. Warner, Sen. Collins and Sen. Klobuchar for proposing this bill.

This bill improves access to advance care planning (ACP) in multiple ways, and improved access is better for value-based health care. ACP conversations are important voluntary conversations that engage patients in sharing their values, goals, and preferences regarding future medical care. Advance care planning is associated with documentation of values and preferences, patient and surrogate satisfaction with communication, and positive surrogate outcomes such as caregiver burden and distress (1). Allowing for billing of ACP incentivizes the health care system to engage in this beneficial practice, and thus far these codes are considered somewhat underutilized.

First, the bill waives the co-pays for ACP visits. At this time, a 20% co-pay applies to advance care planning visits under Medicare Part B. Co-pays are significant barriers to billing and the cost sharing for visits disproportionately impacts communities of color (2). Thus, removing cost sharing for patients addresses health equity concerns.

Second, the bill allows clinical social workers (CSW) to bill Medicare for ACP conversations independently. At this time social workers engage patients in ACP and can bill incident-to a provider visit if a provider is available during the ACP visit. This presents a barrier for some settings and for some health systems. Social workers have expertise and training in facilitating advance care planning conversations (3). Social workers also engage in ACP independently in different health settings. For example, in Veteran Affairs, ACP is a social work led intervention (4). Also, when someone is admitted to the hospital they are asked at admission if they have an advance directive per Joint Commission regulations. In many health systems, if a patient requests additional information, this referral is routed to social workers to provide education and engage patients in conversation. We should empower social workers in the outpatient environment to facilitate these important conversations that they have training and expertise to do.  Allowing CSWs to bill for these services means that patients would have greater access to this care which encourages them to make decisions about their healthcare while they are able to do so.  Many people wish to spend their last weeks at home rather than in the hospital.  Advance care planning is a process and may need to be discussed several times as a patient gains a better understanding of their often changing illness.  

Third, the bill improves access by providing education around using the ACP codes.  The expectation is that this education will help providers gain comfort in using these codes and in documenting ACP conversations. This education will help address structural barriers to billing these codes and engaging in these conversations.

Lastly, the bill directs Medicare’s Payment Advisory Commission (MEDPAC) to study practices and utilization of advance care planning. This can better inform future practice around successfully engaging patients and their care partners in understanding what matters most to patients and aligning care that respects their values and wishes. 

For this bill to be taken up and potentially passed it is imperative that your legislators in the house and senate hear from you. Please contact them to ask them to support and co-sponsor these bills. Phone calls are even better, especially their district office rather than their DC office. Here is where you can look up your representatives here: https://www.congress.gov/members/find-your-member

You can feel free to copy this blog post as the base of your email and adjust as you see fit. An important aspect of advocacy is testimony. You can use your story to leverage change. Share who you are, what you care about (increasing access to ACP), WHY you care about it, and why they should care about it. Then, the ask! When engaging with your representatives, being clear about your ask is very important. In this case we are asking them if we can count on them to support this bill.

Together we can make change happen!!

References:

1. GeriPal Podcast (2020) Advance Care Planning is so right: Podcast with Rebecca Sudore and Ryan McMahan. https://geripal.org/advance-care-planning-is-so-right

2. Grant, M., Freeland, D., Jones, L., & Singh, S. (2022). The equity issue with advance care planning is cost sharing. Health Affairs Forefront. https://www.healthaffairs.org/do/10.1377/forefront.20220314.309752/

3. Middleton, A., Head, B., & Remke, S. (2019). Fast Fact 390: Role of the hospice and palliative care social worker. PCNOW. https://www.mypcnow.org/fast-fact/role-of-the-hospice-and-palliative-care-social-worker/

4. US Department of Veteran Affairs (n.d.) National Advance Care Planning via Group Visits Program, VA.gov. https://www.socialwork.va.gov/ACP_GV.asp