Time to Step Up: Increasing CMS ACP Requirements To Do the Right Thing
How will increasing CMS and CMMI ACP requirements affect you?
We intuitively know that advance care planning (ACP) is a good thing, and something we should all do. But the reality is only about one-third of Americans have documented their advance healthcare preferences, and only a fraction of those completed directives are accessible when patients, their loved ones, and providers need them most.
My career has spanned the healthcare system, from working in a trauma center, to hospital administration, to serving as the President and CEO of Sterling Health Plans, a Medicare Advantage & Medicare supplement company under Aon Corporation and then Munich Re.
I’ve seen the need for ACP from the patient, family, and provider perspectives. Eighteen-year-olds in comas, with grieving parents no longer able to speak for their child. Families outside of intensive care, with no idea what their loved one wanted. Nurses and physicians, knowing the potential outcomes of heroic treatments, but not knowing what the individual valued. As Sterling’s CEO, I frequently visited with our Chief Medical Officer and nurse case managers about what our members really wanted. Often: “No more needles.” And always: “If I could get my family to understand.”
As a daughter of a retired nurse, I personally experienced the healthcare system through the eyes of my mom, as physicians followed best practices but never asked what my mother wanted for herself.
My lengthy career has also allowed me to watch CMMI and CMS regulations evolve. CMS is truly invested in ACP and the long game of ensuring that increased quality and enhanced value are available for all beneficiaries.
CMMI, the innovative sandbox for future CMS regulations, has integrated ACP requirements in all VBID plans and bundled payments. This investment in enabling individual voice has been mirrored by the NCQA with new HEDIS measurers that will ultimately impact Star Ratings.
“Star Ratings,” said a former CMS Administrator, “is how we get plans and providers to do something.”
But perhaps it is time for payers and providers to simply step up and do that right thing, making a difference for the healthcare system overall.
Increasing ACP Requirements Predict the Future
Increasing incentives and requirements for ACP across the healthcare system makes it clear there will be more incentives and requirements, yet to come. Momentum for advance care planning has been building since 2016 and is accelerating quickly with new state legislation and CMMI/CMS mandates. Here are five of particular importance:
1. CMS Advance Care Planning CPT Codes were added to the Physician Fee Schedule on January 1, 2016 to compensate providers for conducting advance care planning conversations.
2. Aspen Health Strategy Group, a part of the Health, Medicine & Society Program at the Aspen Institute, selected advance care planning as its first critical initiative with its concept paper “Improving Care at the End of Life” in 2017. Co-chaired by former Governors and HHS Secretaries Tommy Thompson and Kathleen Sebelius, the push for greater advance care planning has bi-partisan support. The report was a call to action for payers, providers, employers, and the government to normalize ACP electronically and weave it into the very fabric of our lives.
3. VBID Plans (Value-Based Insurance Design). As part of CMMI’s Wellness and Health Planning requirements, plans MUST offer and provide an evidence-based strategy as to how they will:
a. Reach all members/enrollees and ensure a timely offering of ACP
b. Track and measure strategy effectiveness
c. Engage network providers in ACP
Earlier draft versions of these requirements included the possibility of requiring payers to report on whether patients complete an ACP at specific touchpoints such as their Annual Wellness Visits, Health Risk Assessments, or the second physician visit of the year – pointing towards increasing requirements in the future.
Further, Medicare Advantage Organizations (MAOs) MUST have policies and procedures in place and measurably advise members about their rights for treatment decisions and creating ACP documents like advance directives, as well as provide community education on the topic.
4. Healthcare Effectiveness Data and Information Set (HEDIS®) Care for Older Adults Measures from the National Committee for Quality Assurance (NCQA) announced the incorporation of advance care planning as one of its four key measurements to “ensure older adults receive the care they need to optimize quality of life” in August 2021. It requires reporting on the percentage of Medicare members who have had ACP discussions during the measurement year. Member cohorts include:
a. Seniors aged 65-80 who have an advanced illness, an indication of frailty, or are receiving palliative care, and
b. All adults aged 81 and older.
5. Maryland’s House and Senate Bill – Accessibility of Electronic Advance Care Planning Documents. Both SB824 and HB1073 were unanimously passed in the House and Senate in Maryland’s 2022 General Assembly session in April 2022. These bills require several measures to increase public awareness, importance, and the facilitation of ACP documents.
- For Payers, the new law requires they not only offer ACP to all members during open enrollment and periodically thereafter, but they must also arrange to receive status notifications on when members have completed, updated, or shared these plans.
- Providers are required to use an electronic platform to offer individuals the ability to create, upload, or save such directives, as well as identify if they have or have not done so. What’s more, these platforms must offer the ability to identify Health Care Agents (HCAs) and provide counsel that the directives should be discussed with the HCA.
In fact, HB1073/SB824 has been deemed an “Unsung Legislative Action” meaning the item didn’t get headlines but was important as it will impact the health and well-being of every Marylander with minimal cost and substantial benefit.
“These Senate and House bills will impact the health and well-being of every Marylander with minimal cost and substantial benefit. You should know about them.” - Dan Morhaim, Baltimore Sun
So why is ACP now at the forefront?
A few years ago, I co-chaired a Joint Quality Committee for a hospital system. A physician noted that she thought she was treating her patient for diabetes. She said, “It turns out I didn’t understand her priorities at all.” Social determinants of health, Maslow’s hierarchy of needs, racial inequities, and lack of trust for the healthcare system are now understood in the context of healthcare, as we talk about value-based, patient and member-centric care.
The essential next step is to place the values of the individual at the heart of everything we do. Lack of and insufficient access to patients’ advance directives in critical settings is unacceptable, both ethically and financially. Covid-19 exacerbated the need for individuals’ wishes to be documented, and our nationwide focus on health equity has revealed disparities in completion of ACP by race. The cost and toll on patients, their families, providers and payers, and the entire healthcare system cannot continue as it stands today.
As noted in the Pew Charitable Trusts’ The Case for Advance Care Planning fact sheet, we now know that when individuals complete their advance directives, three things occur:
1. Providers and loved ones are more likely to know and respect patient values and wishes.
2. Patients are less likely to receive unwanted and unnecessary medical treatments and procedures in their last weeks of life.
3. Access to completed ACPs results in fewer hospital and intensive care unit admissions and higher hospice enrollment that supports both patients and their families.
Like other initiatives CMS and CMMI have implemented, current regulations are incentive carrots have been dangled to motivate providers and payers. In addition, with the new HEDIS requirements, the implementation of ACP could potentially impact Star Ratings. ACP has become even more than the “right thing to do.”
How can payers and providers stay ahead of ACP requirements?
To quote, as many of us do, Canadian hockey legend Wayne Gretzky, “Skate to the where the puck is going to be, not to where it has been.” Payers and providers need to head to where advance care planning is headed. Not where it’s been.
ADVault has navigated digital ACP more intuitively and proactively for patients, payers, and providers than any other company. I’ve become a Senior Advisor to ADVault because of their ability to address the entire healthcare ecosystem. Their unique ACP solution suite provides for the creation, storage, and access of ACP documents and portable medical orders. Plus, ADVault allows the transition from a paper document world to digital, allowing the upload of existing advance directives and portable medical order forms. ADVault also securely stores ACP documents and portable medical orders in a fully HITRUST-certified repository, while their provider-facing tools track ACP activity so payers and providers can provide both compliance and audit reporting to CMS.
“ADVault navigates digital ACP more intuitively and proactively than any other company for patients, payers, and providers.” - Debbie Ahl – Senior Advisor, ADVault, Inc.
ADVault offers digital advance care planning tools for patients, providers, and payers.
ADVault offers an end-to-end solution suite of digital ACP tools. The three I mention here specifically support payers and providers in offering advance care planning to their members and patients:
1. MyDirectives for Clinicians™ provides healthcare professionals and caseworkers an affordable option to facilitate and document an unlimited number of advance care planning discussions with patients and members regarding their medical goals, treatment priorities, and care preferences for a monthly fee.
2. MyDirectives® award-winning, consumer-facing, and FREE application allows individual consumers on their own to create their advance directives and name healthcare advocates to speak on their behalf and a myriad of other compelling features.
3. MyDirectives Reports & Analytics™ delivers performance metrics to measure and evaluate:
a. Percentage of members and patients who have engaged in ACP as well the upward/downward trends year over year.
b. Timeliness of offering advance care planning and completion of advance directive documents.
c. Providers who pull ACPs so that payers can work with ADVault to determine and analyze the degree of alignment of care rendered and patient wishes.
ADVault is unique with its offering of an end to end solution. These are the five reasons I serve as a Senior Advisor for ADVault:
1. Multiple ways to create an advance care plan.
The first key to successful ACP is to enable the creation of documentation. ADVault offers fully digital completion of an advance care plan, upload of an existing document, or creation of a video message. And, these options can be independently created on the MyDirectives website, or via MyDirectives for Clinicians.
2. Support for existing documents and video uploads.
ADVault offers the ability to upload paper documents, essentially transitioning our paper world to digital access. Both MyDirectives and MyDirectives for Clinicians support document upload to a secure cloud giving members and patients peace of mind their voices can be heard. For even greater clarity, patients and members can also record video messages to help loved ones understand their decisions. Those too can be added to their account and stored along with their other ACP documents.
3. Safe, secure and accessible in the ADVault Exchange™.
It’s not enough to just conduct and document an advance care plan, you need to ensure the information is always available to care teams when and where it matters most – 24/7, 365 days a year.
While there are a growing number of ACP tools on the market to conduct discussions, few offer truly robust security and accessibility. All ADVault’s HITRUST CSF Certified solutions securely store member and patient advance directive information in the ADVault Exchange where it’s always accessible to medical teams via eHealth Exchange, CareQuality, the CommonWell Health Alliance, and a network of state and regional health information exchanges. All elements – advance directives, portable medical orders, and patient videos – are connected to the patient’s account and made available to providers via query and retrieve functionality in their existing EHR platform.
4. Designed for changing circumstances.
Advance care planning needs to support all the possibilities, from future health to potential chronic illness, disability, and death. That’s why MyDirectives and MyDirectives for Clinicians allow both individuals and providers to change and update digital ACP documents and always ensure the most current version is available to the medical team.
5. Measurable end-to-end.
To meet regulatory requirements, it’s important to be able to show your work from end to end: from patient and member invitations to engage in ACP to their documented plans.
ADVault’s reporting tools provide all the performance data you need to measure your ACP program’s performance and effectiveness. As patients and providers engage in ACP, the tools systematically track activity to give payers and providers business insight into:
- Whether a patient or member was invited to conduct advance care planning?
- If offered ACP, when did the patient set up an account?
- Did a provider or caseworker facilitate the discussion? If so, who and when?
- Was a healthcare agent designated?
- Where are they in the process? Incomplete and need follow-up or completed?
- Have they signed their advance directive?
- Where are the documents stored as patients and providers work through the discussion?
- Were the patient or member ACP documents introduced into the ADVault repository via some other patient or member portal? If so, how and when?
- How many plans were put in place?
What’s more, MyDirectives for Clinicians automatically logs every ACP interaction so that you can show regulators that you’re in compliance.
Stepping Up to Digital ACP.
My newly grown out silver hair, compliments of Covid, is an acknowledgement of my lengthy career that has spanned so many aspects of our healthcare system. From this vantage point, I see regulatory momentum on ACP to be a clear call to action for health plans and providers to “step up” to doing the right thing. As it was during my tenure at Sterling Health Plans, our focus should be on how we want our parents or grandparents to be treated. Even without regulatory requirements, if we want to be member or patient centric, we should place individual values at the heart of healthcare.
But the regulatory roadmap does exist, and we need to keep our eyes on where the puck is headed. ADVault’s suite of ACP solutions allows us to adapt to ever-evolving and expanding requirements.
Finally, from a personal perspective, as someone who has experienced firsthand a loved one's journey from challenging health circumstances to their end of life, the privilege to honor one’s wishes is invaluable.
The patient’s voice and what they value has been missing from our best practices and our sophisticated technology and increasing interoperability. Let’s change our systems and focus to start with this voice – with what should be at the heart of healthcare.