September 8, 2015
Andy Slavitt, Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8016
Baltimore, MD 21244-8016
Delivered Electronically through www.regulations.gov
Re: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016
The Center for Medicare Advocacy (Center) greatly appreciates the opportunity to comment on the proposed rule on Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 (CMS-1631-P).
The Center, founded in 1986, is a national, non-partisan education and advocacy organization that works to ensure fair access to Medicare and to quality healthcare. We draw upon our direct experience with thousands of individuals and their families to educate policymakers about how their decisions affect the lives of real people. Additionally, we provide legal representation to ensure that beneficiaries receive the health care benefits to which they are legally entitled, and to the quality health care coverage and services they need.
We commend the Centers for Medicare & Medicaid Services (CMS) for its commitment to delivery system and payment reform initiatives that improve health care outcomes and beneficiary experience while also lowering costs. The proposed Physician Fee Schedule includes many improvements for the Traditional Medicare program to provide better care for beneficiaries. Specifically, we support, and limit our comments below, to: 1) improving payment accuracy for primary care and care management services; and 2) the addition of reimbursement for high-quality, effective advance care planning (ACP).
Section II. Provisions of the Proposed Rule for the Physician Fee Schedule
Improving payment accuracy for primary care and care management services
We applaud CMS’s recognition of care management as a critical component of primary care, and its commitment to changing payment accordingly. We appreciate the steps CMS has already taken to refine the Physician Fee Schedule (PFS) to appropriately value care management (for example, by paying separately for transitional care management and chronic care management), and the continued commitment reflected in this year’s PFS. We support adjustments to codes to reflect more accurately the extensive cognitive work and increased interdisciplinary collaboration required in chronic care management.
We urge CMS to continue to pursue payment changes that reflect and recognize the activities and effort physicians and other practitioners dedicate to partnering with patients and families in managing care. The most effective care management activities are done in partnership and collaboration with patients (and as appropriate, family caregivers). When done well, partnering with patients and families on these activities may require additional time and resources on the part of clinicians, but yield more successful care management strategies that better meet the needs of patients and families and lead to better health outcomes. To this end, we encourage CMS to consider codes that reflect the additional time required to collaborate with patients and families. To ensure meaningful engagement and to avoid gaming or abuse, such codes should be accompanied by appropriate consumer protections and by robust quality metrics that emphasis patient-reported outcomes and experience.
Consumer protections should include documentation of conversations about care planning costs and cost-sharing, mandatory documentation of privacy decisions, and mechanisms for patient feedback. We also encourage CMS to closely monitor concierge and other extra services physician arrangements. As enhanced care coordination is increasingly compensated for under the Medicare physician fee schedule, concierge arraignments that offer only this additional benefit may no longer be appropriate under the Office of the Inspector General (OIG) rules.
Establishing Separate Payment for Collaborative Care
We strongly support efforts to reward physicians for inter-professional consultations and collaboration, especially between primary care and specialist providers. However, we believe that beneficiaries should be fully aware of the involvement of specialists in their care, as well as the associated benefits and costs of the collaboration between the beneficiary’s primary care provider and a specialist.
Because of the financial liability that collaborative consultations between providers could place on beneficiaries, we strongly support CMS’ proposal to consider a Center for Medicare and Medicaid Innovation (CMMI) model to test the effectiveness of a waiver of beneficiary cost-sharing for such inter-professional consultations. As CMS states in the proposed rule, without appropriate beneficiary protections and notifications concerning inter-provider collaboration, the beneficiary could end up paying for services they were not aware were being rendered. In considering such a waiver, CMS should also consider audit and other enforcement mechanisms to ensure that services are actually being provided, as beneficiaries may be less likely to notice or report billing for services not rendered if they are not subject to cost-sharing.
We also support requiring integration of health information technology into collaboration efforts undertaken by primary care and specialist providers. Specifically, as part of collaborative care/care management services, we suggest that CMS implement similar requirements to those proposed for the Meaningful Use program: providers should be encouraged to electronically send “summary of care” documents and to incorporate these documents into transitions of care.
Finally, as we transition into new delivery system models that emphasize team-based care, we note that, in the future, these electronic platforms can support collaborative care by connecting all individuals involved in the care of a beneficiary—including their providers, social supports, family members, and beneficiaries themselves—in the collective work towards individually-identified goals. As the field of collaborative care evolves, we encourage CMS to look to future uses of technologies like electronic platforms and applications to support partnerships between beneficiaries, families, and their care team.
Valuation of Specific Codes
Advance Care Planning
We strongly support the proposal to add new codes recognizing separate payment for advance care planning (ACP). According to the National Institute of Aging, more than one in four older adults face questions about medical treatment near the end of life, but may not be able to make those decisions on their own. Cognitive impairment is common among older adults; in fact, some estimates show that over 40 percent of older adults have mild dementia or cognitive impairment and over 20 percent have severe dementia—such conditions contribute to the difficulty of individuals making end-of-life decisions on their own. Unfortunately, most people have no documentation of their preferences for care at the end-of-life or during incapacitation, and very few have even talked with their family or provider about their wishes. We commend CMS for expanding payment for additional advance care planning.
Advance care planning allows patients and families to learn about the types of decisions that they might need to make near the end of life, and to consider those decisions ahead of time. Importantly, advance care planning also allows patients to alert others, including providers and family members, about their preferences and legally document those preferences, in case the patient later becomes unable to speak or advocate for themselves. Advance care planning should encompass the whole process of discussion of end-of-life care, clarification of end-of-life values and goals, and recording of preferences in written documents and medical orders. According to the Institute of Medicine, advance care planning conversations should:
- Occur with a patient’s designated health care provider along with appropriate members of the clinical team and with patient-identified family caregivers;
- Be recorded and updated as needed; and
- Allow for flexible decision making in the context of the patient’s current medical situation.
We appreciate that the proposed codes incorporate many of these standards and goals, providing flexibility to extend care planning discussions beyond a thirty minute deadline and to schedule discussions for times that best suit patient needs.
Advance care planning gives patients, and their families, the opportunity to prepare mentally and emotionally for death. Older individuals who have discussions about their end-of-life planning are much more likely to have their end-of-life preferences known and followed, and their family members suffer significantly less stress, anxiety, and depression after their family members’ deaths. However, many patients may be reluctant to engage in advance care planning unless it is initiated by their provider.
To implement effective advance care planning, working closely with patients and their families is critical. Implementation of and reimbursement for advance care planning should be designed to give beneficiaries and their families the support they need at the appropriate time, in an appropriate setting, delivered by the appropriate team of qualified individuals. Trained providers should:
- Proactively begin conversations with patients and family about end-of-life planning.
- Incorporate shared decision making into the conversation, through patient education and discussion of goals, values, and clinical evidence.
- At first assessment and at frequent intervals as conditions change, document the patient’s preferences for goals of care, treatment options, and setting of care. Health and care plans should be goal-oriented, dynamic tools (not static documents).
- Convert the patient treatment goals into medical orders, and ensure that the information is transferable and applicable across care settings, including long-term care, emergency medical services, and hospital care.
- Make advance directives and surrogacy designations available across care settings, while also protecting patient privacy. Health information technology should support provider, patient, and family caregiver access to the patient’s advance directive (and/or other personal information documenting the patient’s preferences) from multiple care settings.
- Respect and accommodate the ethical, spiritual, and cultural values of all patients.
To this end, we encourage CMS to expand the scope of services payable under the advance care planning benefit to include the services of non-health professionals and to incorporate non-face-to-face services where necessary. Non face-to-face services might include communicating with designated family caregivers who are not able to attend in-person appointments, answering clarifying and follow up questions, or providing coordination and referrals to non-medical professionals such as clergy or legal services. We also encourage CMS to develop clear standards for practices that furnish advance care planning services – such as, for example, required adoption of certified electronic health records or required demonstrated use of evidence-based policies, procedures, and training – to ensure that practices have the capability to furnish these services at a high quality.
Additionally, we believe that comprehensive advance care planning should occur in the greater context of shared care planning and shared decision making, in partnership with the patient and his or her designated family caregivers. Proactively and explicitly engaging an individual’s family and caregivers in the development of a care plan helps to ensure that the individual’s abilities, culture, values, and faith are respected and care instructions and action steps are more likely to be understood and followed.
While human interaction drives the process of care planning, technology can help make necessary information more readily available and actionable, connect all people who have a role in an individual’s care plan, and provide a shared platform for the ongoing maintenance and management of an individual’s care and wellbeing. Electronic platforms also make it possible to scale plans according to individual needs and various stages of life. This type of electronic tool, which allows all care team members to work towards goals identified by the patient, can facilitate a dynamic process of shared decision-making and advanced care planning.
While we are strongly in support of advance care planning codes, we encourage CMS to consider connecting provider reimbursements to the quality outcomes of advance care planning and not to the process alone. Providers must be held accountable both for delivering high-quality advance care planning and for delivering health care that is in accordance with preferences documented in advance directives. Quality measures evaluating providers on advanced care planning should, for example, capture:
- Patient verification of a meaningful discussion of advance care planning;
- Patient verification of an advance care plan in the patient’s health record;
- Patient verification of updates to the advance care plan as appropriate; and
- Patient reported data on how closely care received aligns with the advance care plan.
We also urge CMS to continue to consider ways to make these codes work for beneficiaries and providers. For example, we support payment for these services for all Medicare beneficiaries, not only to ‘manage and treat’ a current condition. Indeed, we see advance care planning services as the ultimate preventative service – preventing misunderstanding, unwanted interventions, and default, generic decision making where individualized choice could be possible. In that light, we strongly support CMS’ proposal to make ACP available, with zero cost-sharing, both as part of the annual wellness visit and separately.
In fact, we believe that ACP must be implemented without cost-sharing for it to be effective, as beneficiaries may forgo a service if faced with the prospect of paying for the service.  Furthermore, beneficiaries already dedicate a significant portion of their income to medical expenses. Eliminating cost-sharing for this service will also enhance the promise that the APC benefit has to reduce health disparities faced by low-income beneficiaries and limited English proficient beneficiaries who do not currently have the same access to ACP. Data demonstrates younger, poorer, minority, and less-educated individuals, do not have end-of-life conversations with the same frequency as their older, higher educated, white counterparts. Researchers suggest that these differences are caused by “cultural and religious differences, communication challenges between patients and medical staff, distrust of medical care systems, and awareness of advance directive options.” “Advance care planning mechanisms dedicated to the needs of individuals within these groups are needed to facilitate access to necessary care and to ensure that preferences for care are recognized and honored.”
We also strongly encourage CMS to commit to significant beneficiary and provider education about the ACP benefit. The Institute of Medicine’s examination of end-of-life issues emphasizes the need for public education. “Efforts are needed to normalize conversations about death and dying. Several social trends suggest that the time is right for a national dialogue on this issue, including health care beneficiaries’ motivation to pursue high-quality care for themselves and their loved ones; a growing willingness to share stories about end-of-life care experiences that resonate across diverse groups; and emerging leadership in local communities as well as national coalitions and collaborations.” Given the sensitivity of end-of-life issues, and the potential for misunderstanding, it is imperative that both providers and the public are educated about exactly what the ACP benefit is, and is not.
The Center greatly appreciates the opportunity to provide feedback on the proposed rule on Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 (CMS-1631-P). For further information please contact Center Senior Policy Attorney David Lipschutz, firstname.lastname@example.org.
Center for Medicare Advocacy
 National Institute on Aging, U.S. Department of Health and Human Services. (2014, March.) Advance Care Planning. Retrieved 24 August 2015, from https://www.nia.nih.gov/health/publication/advance-care-planning.
 Nicholas, L. et al. (2014, April.) Advance Directives And Nursing Home Stays Associated With Less Aggressive End-Of-Life Care For Patients With Severe Dementia. Health Affairs. Retrieved 24 August 2015, from http://content.healthaffairs.org/content/33/4/667.full.
 (IOM) Institute of Medicine. (2015.) Dying in America: Improving quality and honoring individual preferences near the end of life. Retrieved 24 August 2015, from http://iom.nationalacademies.org/Reports/2014/Dying-In-America-Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx.
 Adapted from National Quality Forum. (2006, December.) A National Framework and Preferred Practices for Palliative and Hospice Care Quality. Retrieved 24 August 2015, from http://www.qualityforum.org/Publications/2006/12/A_National_Framework_and_Preferred_Practices_for_Palliative_and_Hospice_Care_Quality.aspx.
 For more information, see, e.g., the National Partnership for Women and Families’ Care Plan 2.0: Consumer Principles for Health and Care Planning in an Electronic Environment, available at http://www.nationalpartnership.org/research-library/health-care/HIT/consumer-principles-for-1.pdf.
 Leadership Council of Aging Organizations (LCAO) Issue Brief: Beneficiary Characteristics. (June 2014) available at: http://www.lcao.org/files/2014/07/LCAO-issue-brief-bene-characteristics-updated-June-2014-7.8.14.pdf.
“On average, in 2012, Medicare households spent 14% of total costs on health care; whereas, non-Medicare households spent just 5%. In 2010, more than half of all Medicare beneficiaries spent more than 16.4% of their income on health care costs.” Id.
 Kaiser Family Foundation “10 Frequently Asked Questions: Medicare’s Role in End of Life Care” available at: http://kff.org/medicare/fact-sheet/10-faqs-medicares-role-in-end-of-life-care.
Office of the Assistant Secretary for Planning and Evaluation, HHS “Report to Congress” (August 2008) available at: http://aspe.hhs.gov/basic-report/advance-directives-and-advance-care-planning-report-congress.
Institute of Medicine “Dying In America: Key Findings and Reccomendations” (2014) available at: http://iom.nationalacademies.org/~/media/Files/Report%20Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf.