Lifting the barriers to end-of-life conversations

  | November 10, 2016

Most people say that, when the time comes, they would like to die peacefully at home, surrounded by family. Few do.

Instead, a third of Americans die in hospitals. And as many as 70 percent have not documented their wishes for medical treatment at the end of life. To honor more patients' wishes — and reduce the rate of costly, unwanted interventions — the Centers for Medicare and Medicaid Services (CMS) introduced two new CPT codes on Jan. 1, 2016. Now, physician time spent helping patients clarify and record their wishes in advance directives is reimbursable in unlimited 30-minute increments. Advance directive conversations over time, athenaResearch, athenaInsightYet most doctors aren't taking advantage of the codes — and, presumably, aren't talking to patients about advance directives. An analysis of 3.2 million patients ages 65 and older on the athenahealth network found that fewer than 1 percent of them — 0.61 percentspoke with their primary care providers about their preferences for end-of-life care between January and September 2016.

That data matches what physicians are saying. In one poll of 756 primary care doctors and specialists in April 2016, 75 percent said Medicare reimbursement makes it more likely they would have end-of-life planning discussions with patients. Yet just 14 percent of those providers said they are actually using the new codes.

The cost of that lack of progress is significant. In 2014, Medicare spent an average of $34,529 per person on end-of-life care compared to$9,121 on care for beneficiaries not at the end of their lives.

“If we could honor what people want, it would be a huge savings," says Harriet Warshaw, executive director of The Conversation Project, a campaign to promote end-of-life conversations among families and their physicians.

Signs of change

A closer look at billing patterns across the athenahealth network indicates that change may be on the horizon. The number of primary care practices on the network billing for discussions of advance directives jumped 154 percent by the end of September. End-of-life conversations with patients over time, athenaInsight Among those practices that are using the codes, uptake has been swift. The number of visits in which discussions took place increased by 297 percent overall by August.

And a small cohort of practices on the network have incorporated end-of-life conversations steadily into their clinical routines. Some have been billing for time spent helping patients document their wishes for as many as 60 percent of their patients 65 and older.

“Honestly, the data paints an optimistic story," says Ravi Parikh, M.D., a third-year internal medicine resident at Brigham and Women's Hospital in Boston who will become a fellow in oncology in 2017. An advocate of formal training for residents in end-of-life conversations, Parikh frequently cares for patients in their final illness. End of life conversations billed over time, athenaInsightWith any healthcare intervention, Parikh says, "you never see a 100 percent uptake within a year." But to increase use of the codes even more, he says, institutions will need to support their physicians.

“Billing is one step, but culture change is a huge step," he says. "We're only going to be billing for these codes when we know what to do in these conversations."

And to know “what to do," experts in palliative care say, physicians will need specific training and technological support.

Both outpatient and inpatient physicians often struggle to find the right language when speaking to patients about end-of-life care, says Kate Lally, M.D., chief of palliative care at Care New England.

“Some docs are good at it, some aren't," she says.

Lally's organization was a Pioneer Sponsor in the "Conversation Ready" initiative, a collaboration between the Conversation Project and the Institute for Healthcare Improvement, which aims to ensure that healthcare systems are prepared to receive and respect patients' wishes for end-of-life care.

Once they learn the art of leading a comfortable conversation in which a patient's wishes emerge, says Lally, physicians can “craft a treatment plan that will meet those goals, given their medical diagnosis."

But as of 2016, 68 percent of physicians report that they have not received training for such discussions, according to a Kaiser Family Foundation analysis.

Documenting patients' wishes presents another challenge, physicians say. When conversations are held, they are sometimes simply checked off in an electronic health record as a quality measure, without detailing the directive.

In other cases, an outpatient EHR may contain a patient's directive, but an inpatient EHR might not.

Or, says Parikh, the information could be in the EHR, but “segregated in a very hard-to-find place." Whatever the cause, the provider at the bedside may not be able to surface the record of a patient's wishes in the moment it is needed most.

The solution, says Lally, must come from the top. Health systems like Care New England that build processes to ensure that patients' last wishes are known and respected — to be “conversation ready" as Warshaw's group urges — are finding more success.

When she runs up against barriers to helping patients manage their final months, Lally says, “I know that the leadership has my back and says, 'No, this is important work. This is central to the work of the future.'"

Gale Pryor is a senior writer for athenaInsight. Data analysis by Anna Zink.

Lifting the barriers to end-of-life conversations