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March: National Ethics Awareness Month and the Use of a Medicare Voluntary Advance Directive Framework

Stephanie Frilling, Maureen Merkl, Alexander Holston, MD, Linda Nadrowski

March 12, 2024

Health & Civilian, Health, Innovation in VA Health, Medicare

As National Ethics Awareness Month, March offers an ideal time to contemplate the principles of medical ethics and the responsibilities of federal leaders and clinical providers to evaluate improvements that promote ethical care. With over 58 million Americans over age 65 enrolled in Medicare, Centers for Medicare and Medicaid Services (CMS) policy makers have a growing responsibility to advance end-of-life care quality and satisfaction. Establishing a nationwide voluntary advance care planning framework empowers Medicare beneficiaries to thoughtfully explore their values, ethics, and health goals while documenting care priorities. This process assists surrogate decision-makers and culminates in more patient-centered end-of-life care, reducing unwanted interventions. By empowering patients to express treatment preferences, this framework eases choices for loved ones and points the way to ethically aligned, compassionate care as life’s final chapter unfolds. 

Purpose of Advance Care Directives

An advance directive catalogues a person’s healthcare preferences to clarify these decisions even when the person cannot communicate them. The directive guides healthcare providers and relieves family members from making difficult decisions during emotional times. A Medicare Voluntary Advance Directive Framework would enable the creation, storage, and sharing of advance directive documents, so care appropriately honors the individual’s wishes. 

Medicare beneficiaries can consider quality of life, healthcare burden, pain management, religious beliefs, and the ability to live independently in documenting their care choices. Some can elect for intensive care and instruct providers to make every care intervention possible while others can prioritize comfort and peace as the end draws near. 

Challenges for Implementation 

Implementing a nationwide advance directive registry poses challenges regarding state-specific end-of-life care laws, documentation, and regulations. Each state has its own governance surrounding these matters. Additional barriers, such as accessibility, legal clarity, awareness, and electronic health record (EHR) and registry interoperability, obstruct these instruments. Some states and systems offer these services, complimentary or for a nominal fee. 

Nationwide efficacy in furnishing advance care based on an individual’s directive requires successful and secure data management at the federal level. The federal government must assist providers and Medicare beneficiaries with navigating documentation and legal variations of approved forms and ensuring that privacy standards keep an individual’s health data secure. 

Medicare Advance Care Planning Services  

In 2016, Medicare encouraged voluntary advance care planning (ACP) when it included the ACP service as part of the Annual Wellness Visit and a standalone service. A Medicare payment is available for eligible providers when furnishing ACP services to a patient, family member, or appointed care surrogate. Medicare uses Common Procedural Terminology Codes 99497 and 99498 to report the first and additional sessions for payment. Approved Medicare providers are not limited by the place of service or frequency with which these codes are billed. CMS stipulated a generous payment to encourage providers to engage with Medicare beneficiaries and family members at the right time for the individual, ranging from a primary care office visit to an acute care episode.

During ACP services, providers record a patient's care preferences in EHR documentation. Currently, no requirement details the storage or retrieval process of documentation garnered during ACP services. This gap results in a lack of awareness about patients’ care wishes among family members, caregivers, and healthcare providers at critical moments. 

Including a Medicare Voluntary Advance Care Framework with the ACP service would create a comprehensive suite of tools to make advance directives available to providers. The framework would guarantee secure access to designated parties, support the periodic update of directives to reflect changes to the patient's health conditions, and facilitate the distribution or retrieval of these documents in a secure system.

In addition, a growing body of evidence supports the use of advance care directives to reduce Medicare spending in the last year of life. Some provider groups have begun to test ACP incentives as furnished in Accountable Care Organizations (ACOs). A study found that ACOs that increased end-of-life documentation reduced overall program costs. 

Advancing Equitable Care at End-of-Life 

Underserved and marginalized communities often have limited or unreliable access to healthcare information management. A Medicare Voluntary Advance Directive Framework would support the equitable delivery of advance care by offering meticulous management and upkeep as a dedicated data and document repository available to providers across the continuum of care. The registry would further health equity, recording and protecting individual healthcare directives and bridging the availability gap in regions with health disparities. 

By swiftly and seamlessly incorporating accessible advance directives into healthcare delivery, Medicare will improve quality of care and satisfaction for its beneficiaries and uphold the dignity of personal healthcare decisions across all demographics. 

LMI Value and Innovation

Driving innovation for a better tomorrow, LMI offers advanced analytics and digital capabilities and a dedication to enhancing public health, making it a uniquely qualified choice to develop a Medicare Voluntary Advance Directive Framework. Leveraging a rich history of managing intricate datasets and a robust grasp of federal regulations, LMI can craft a pioneering solution that not only fills care gaps but promotes equitable health outcomes for all.