In this episode of the Move to Value Podcast we continue our conversation with Dr Kim Vass-Eudy, Senior Director of Clinical Operations at CHESS, about Advance Care Planning and how to document those patient interactions.
Dr Kim Vass-Eudy, welcome to the move to value podcast, it’s good to have you back!
So last time we talked about a lot of the factors that go into advanced care planning, how the provider sometimes has to wrestle with decisions, perhaps feel some discomfort with acknowledging end of life and that it perhaps goes against all of the training that a provider has. Before we left, you touched on some of the financial components that are involved in advanced care planning and, you know, as uncomfortable as this conversation might be to have, talking about the financial component might be just as uncomfortable.
But I do think that there is a good motivator to have these conversations with patients beyond the benefit to the patient and that would be how the provider would be compensated or reimbursed for having those office visits, which we all know is is part of the business of healthcare. So it it’s been said that the success of an accountable care organization is not about whether physicians should give their patients more care or less, but it’s about having the right conversation with the right person at the right time and being able to act on that person’s wishes for their health. So as we move away from, you know, the discomfort of those conversations, I just want to touch one more time on how having these conversations, before a patient before they’re actively dying, how they impact the metrics for success and value, like patient satisfaction, quality, utilization, and cost reduction. That’s a long question, I apologize
Very big very I might have zoned out for a minute there.
OK, I apologize for that so I think what we’re trying to really distill this down and to being is having those conversations do impact value and can you tell me maybe how that is how and why that is so?
Yes I can.
You’re welcome, let me save you from yourself Thomas
I appreciate that, thank you thank you – verbose, that’s what we are.
So within ACOs, so an accountable care organization, our goal is really to give, like you said, the right care at the right time to the right person, and in doing so sometimes you have to look at the cost of the care. That’s the bottom line. We spend too much money in healthcare, and we need to make sure that we’re spending it properly and on the right people and making the most impact on the people that we’re touching. So that being said, when it comes to end of life that is the most expensive time of our lives when it comes to our health care cost, and it doesn’t have to be some of the reason it is is because people have not laid out what their desires are for their end of life and their family members say do it all. You know, give them do everything that you can possibly do for my family member, my loved one, when maybe that person did not want those things done. Maybe they had a different vision of how their life would process or become you know their life their end of life would occur. So, having that conversation what is it that it looks like to you at your end of life? Do you want every machine? Do you want every antibiotic? Do you want every intervention? And the patient can really make that decision ahead of time they don’t have to wait till the last minute, they don’t have to rely on their family members in a moment of feeling very vulnerable and upset and emotional. That it can all be laid out ahead of time and that would save money.
Now, here’s the thing. Patients, this is kind of an interesting statistic, so patients who’ve had an advanced care plan discussion within three months of dying actually spent more money. They had more interventions. But a patient who had the advanced care plan discussion a year ahead of time ahead of their death, they actually chose more conservative measures. What does that mean exactly? My interpretation is that when you’re so close and you’re not really giving it much thought you’re like do it all or your family member says do it all, but if you’ve had time to process you’ve had that year, you can think about it. You can say well maybe that’s not my choice. Maybe I would choose a more conservative measure. Maybe I would choose palliative care or Hospice, and we find that patients who have advanced care plan discussions with their providers, do choose palliative care and Hospice interventions more than others.
We also find that there’s an overall decrease in utilization. There’s an overall decrease in hospital stays and admissions for patients who had advanced care plans. There’s a decreased cost of end of life care without increased mortality. It’s not like we’re letting people suffer. We are not spending as much money but they’re still living just as long in that end-of-life season. So that just thinking about it in money terms and I think that’s the tough part because it’s like it’s the end of life you want to preserve life but at the same time at what cost? So this is an interesting thing though, when patients have had an advanced care plan, they’ve discussed it with their family, their family knows their wishes, they actually have increased satisfaction from both the patient and the caregiver. Knowing what the right choice is, getting that ahead of time, there’s no pressure. We know if this is happening to mom, this is what mom’s wishes are I will grant mom her wishes and the family and the patient are more satisfied with that. So as hard as it is to have the discussion about money, we do save money when we have an advanced care plan but the patients and their family members are also happier with those choices.
That seems to go against what you would expect, but in some ways it does make a lot of sense because I think what we all look for at the end of life is contentment and closure and if you’re not if you don’t have that mental preparation beforehand, it becomes very terrifying and you sort of scramble that’s right yes it’s like you’re grasping you’re cramming for the exam of transitioning yeah out of this life yeah. That being said treatment choices near the end of life are typically not simple, consistent, logical, linear, or predictable. They’re complex, uncertain, emotionally laden, and fluid. So how do we make sure that the wishes of a patient are kept as sort of that north star that GuideStar for clinical decisions?
The discussions are one place, so when the provider knows, and then putting it down formally on paper is another, the patient having the discussion with their family so their family is aware is another. There’s many times when the when the discussions not had and you know daughter from New Jersey comes in and she’s taken over, but she doesn’t know what mom wants. So having the discussion is important, getting it down on paper so everyone knows what it is especially when they get to the hospital or they’re in Hospice care or in palliative care, everyone knows what the patient is wanting. And here’s the caveat: they can change their mind anytime they want to. This does not, just because they wrote it down, just because it’s signed, doesn’t mean the patient can’t change their mind, because they can and we can redocument that. We can just put in documentation all over again. So it is fluid, it is complex there are emotions involved, and it’s OK. We do the best we can. This is one way to outline it so that we can try to make the best decisions for the patient as possible and they can change their mind anytime.
Do you see folks changing their mind the closer they get to perhaps the end of life or…?
Personally, I have not, no. I think anyone who’s been in the position where maybe they saw a family member pass, there is a time when I feel like most people understand that there really is no turning back, that no intervention is going to change anything, and there is an acceptance of that. And it’s, personally, it’s a moment that I find very reassuring I guess because I hope that when it comes my time that it feels OK. That I’m not scared or that I’m not grasping or but that it’s a an acceptance like this is next step you know this is where I’m headed and that’s OK I’m OK with that.
So, as we dip more into the financial component from the provider, the accountable care organization, you know, the standpoint outside of the patient purview, what type of documentation for reimbursement for these conversations is required for providers who have the advanced care planning discussions with their patients?
There are two codes, so it’s pretty easy. The first code is 99497 and that is a code that you can use for the first 30 minutes of a face to face discussion with a patient, a family member, or a surrogate. And it can be a minimum of 16 minutes so it doesn’t have to be 30 total but from 16 to 30 minutes really. The other code is a 99498 and that’s for each additional 30 minute discussion on top of the 99497. And in both of these, there is no requirement to have any kind of forms filled out, no advance directives filled out, it’s just the basic discussion of end of life care and advanced care planning with the patient. You do have to document though to be able to justify these codes and you have to show that the patient was voluntary that they had this discussion with you on their own accord, that you explained what advanced directives are, you have to write down who was present, so if it’s daughter and patient, or if some other family member you need to write down their names, you have to say what the amount of time was spent face to face encounter, and then document any change in the health status or the health care wishes if the patient becomes unable to make their own decisions, so that if that needs to be changed if you’re writing this and it needs to be changed you need to document what their wishes are. So it’s not difficult and these codes can be used anytime. It’s not like it’s a one and done. I typically use this at a well visit. So I have a patient who comes in for their yearly visit, we start to have the conversation, it’s 16 minutes or longer, I use the 99497 code, and I can do it again next year. There’s no real limit to how many times I can use it. Of course, once I’ve done it maybe next year we discuss it again, so it just is one of those things that you can use more than once.
You know when we look at documenting, encoding all of the different diagnoses that a patient has, and I know that as one of our colleagues say, you know every year amputees grow a new limb, everyone gets an everyone’s cured again, and we have to read document everything. So it sounds like this is another tool that it can be used annually when you have those conversations so that is then a motivator for the provider to have those conversations.
I think so, yeah I mean we’re we have done a job and we should be compensated for the job so this is one way to prove it. And honestly, Thomas, like I could do this in six months. I could do it now with their year their yearly well visit and when I see him in six months hey do you want to talk about what we talked about last time? Do you want to go over that? do you have any questions about that? And I could code it again if that’s a 16-to-30-minute conversation. So it doesn’t have to be a whole year in between, but typically that’s how I do it, just cause the well visit is a reminder to me, oh maybe I should talk about that you know now. But if it was one of those things where maybe I wrote myself a message hey you told him about it maybe I gave him a form in six months maybe I’ll say did you bring that form back, did you have a chance to talk to your family about it, and I can code again. So it’s one of those anytime you want the conversation to happen you can use that code.
Well, this has been very helpful. I’m sure that there are many aspects of advanced care planning that I have neglected to ask you about. Is there anything that you feel that would contribute to this discussion?
Yeah I think, so providers often are uncomfortable with this and there is help. So, if you feel like this is something I just am not ready for don’t know how to do, a lot of our local Hospice and palliative care organizations offer education for the provider and for the family members. We are working with an organization with CHESS. We’re partnering with an organization and they offer group sessions for patients and their family members to talk about advanced care planning. They offer education for providers, which I’m going to take advantage of because I’m sure I could learn many many more things about this and I you know I’m just doing it from my work I don’t I’ve never been formally trained in any way, so I definitely want that. So I would say if anyone is interested beyond what we’re talking about beyond articles beyond our podcast is that the Hospice palliative care organizations within your community are a great resource for helping you and your patients with this process.
Wonderful! Those folks do some amazing work.
They really do.
Dr. Kim Vass-Eudy, thank you for joining us today on the Move to Value podcast.
Thank you, Thomas. This was a difficult conversation, but it was actually, I feel like it’s enlightening for most people because they’re having trouble with it as providers. Patients do want to have the conversation, so I hope this has sparked an interest in some of the providers that maybe they’ll start implementing this in their practice.
I hope so too. Thank you very much!