I know the following may convey a lack of gratitude. CMS funds a code, and by doing so, validates an activity for so long many in medicine have overlooked or dismissed. Many specialists probably viewed end of life counseling as “stuff” those docs in the offices without the cherry finished cabinets dealt with. You know. Trivial stuff. Well, at least we can put that little contrivance to bed. Amen.
Cash is hard to come by these days and introducing a newly funded service risks cost overruns from overuse. But if I had to guess how often practitioners will utilize these new E/Ms (99497 and 99498), my bet would be less than expected–and CMS can ease their fears that providers will back their Brink’s truck in.
First, we have no National Coverage Determination (NCD) for their use. In the absence of an NCD, CMS will cover an item or service at the discretion of the Medicare contractors based on Local Coverage Determinations (LCD). You may think because a code exists, CMS will pay for it. It does not. One contractor might ding the service in jurisdiction four, and another will let it sail in eight. Because rejection rates will vary, we need a uniform endorsement from on high to get all fifty states in sync.
Second, along with other best-laid plans, and think care transition, obesity consultation, and chronic care management codes, the hassle factor and lesser value CMS places on advanced planning counseling will effect how providers apply them. Transition and CCM codes, frankly, have been duds.
The burdens and strength sapping properties of care coordination and the accompanying conversations that go along can tax even the saintliest of individuals. In the case of advanced planning, it’s not just thirty minutes of human interaction. It’s thirty minutes of draining human interaction–and those who perform these tasks, know they have no equivalent in most other’s daily routine. When giving a shot pays more than an affecting exchange, docs take note. Again, do not count on widespread uptake. Experience shows the creation of a code does not imply physicians will employ it.
Third, the minority of providers who have performed end of life services in the past will likely be the ones who continue to do so (you may have heard EOL counseling is a skill). Doctors who once billed regular codes at a higher intensity to account for their efforts will downgrade or substitute them for the up-to-date entries. New E/M benefits will serve as passable add-ons at best, but will not attract legions of new docs. Their existence will encourage those providers who typically bypassed these discussions to refer their patients to those folks who were already taking them on.
To muddy the waters further, at least on the inpatient side, the parallel universes of palliative care docs, geriatricians, hospitalists, oncologists, and intensivists will engender confusion on the back end when 99497 or 99498 get double billed. It’s not uncommon for any one of the specialists above to engage in prolonged dialog with a family or patient, only to have a different doc from the same physician cluster repeat a similar conference later in the day.
I presume, in facilities where they practice, palliative care docs will eventually own the codes—but not without adjustments along the way. We have not established boundaries for advanced care planning conversations and smoothing out the process will take time.
Finally, I wish to remark on the distinctive biomedical model of healthcare delivery we have in the U.S. (versus a population health approach familiar to the rest of the world). Proceduralists and some subspecialists believe, based on the values shaped and imbued by our system—and many parties helped set them (the RUC, NIH, AAMC, et al., come to mind), that “doing stuff” holds more value than “thinking stuff.” CMS validates the same when they pay more for taking off a mole or giving a trigger point injection rather than discussing death and dying. Right. Tell you something you don’t know.
Reform will edge forward. Old paradigms will not perish without conflict. And unless physicians advocate for change from within, no one else will take it on and do it for us. Bundled and global fees will accelerate the shift–distributing unassigned dollars presents new possibilities–but lobbying by, shall we say, the patrician sect will deter any immediate turnarounds.
With exceptions, we have overvalued procedures and diagnostics. The system will not give more, so other doctors will have to take less. There. I said it.
Regardless of code uptake, some regions will outperform. Pockets of successes (and failures) will emerge and serve as grist for inquiry. You can bet hungry health service researchers are polishing their spreadsheets as we speak, awaiting the out years to determine how code use impacts resource utilization and patient quality of life.
As always, cautions apply, and many of the questions unresolved today will continue to remain unresolved into the next decade. Regional culture, secular trends, code attribution, confirming advanced planning documentation use (versus just attainment), and other uncertainties will skew analyses and strengthen any preconceived beliefs vested parties or individuals might have.
Will paying for advanced care planning work? Does it save or waste dollars? If I had to predict, we will find small but significant positive associations between code use and outcomes–with the usual caveats of study confounding and bias (I can already envision the Dartmouth map).
Again, those who believe will continue to do so and observe the data glass as half full. Those who don’t will observe the same data, and view the identical glass as a less than half empty vessel. I believe we will still have more questions than answers, along with continued code undervaluation and subpar administration, when I rewrite this post in 2017.
I do hope health systems, CMS, and the house of medicine converge a bit more, however, on the worthy goal of promoting a service very few would deny is challenging, woefully undervalued, and to the public’s advantage.
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.
Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.
Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.
He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.