INTRODUCTION

Advance care planning (ACP), the process of discussing and recording patient preferences for goals of care in the event of the patient losing capacity has been widely acknowledged as key to ensuring care delivery concordant with patient preferences.1, 2 Provider-perceived barriers to ACP have been documented, such as lack of time or reimbursement.3 Medicare began reimbursing providers for ACP in 2016. Previous studies found overall low rates of ACP billing, with wide variation by patient socio-demographics and physician specialty.4, 5 Very little is known about the physician or practice characteristics associated with ACP billing, and no study has examined ACP billing among non-physician providers. We used a nationally representative sample to identify the characteristics of physicians and advanced practitioners (APs) associated with billing for ACP.

METHODS

We used a 20% nationwide random sample of Medicare Part B claims for 2016 and 2017 merged with the Medicare Data on Provider Practice and Specialty, Medicare Shared Savings Program Provider Accountable Care Organization (ACO) Provider file, Medicare Electronic Health Records (EHR) Incentive Program (Meaningful Use) Public Use File, and IQVIA Physician Database.6 Our study population included physicians and APs (nurse practitioners and physician assistants) with 100 or more Part B claims in 2016 and in 2017. ACP billing was identified by current procedural terminology code 99497 or 99498. We conducted logistic regression analyses predicting the probability of ACP billing using the following characteristics: age, gender, Meaningful Use participation, foreign medical school training, Medicare ACO participation, practice size, and rural location. We estimated the regressions separately for generalist physicians (internal medicine, family practice, geriatric medicine, general practice, hospitalists), specialist physicians, and APs.

RESULTS

Our study population included 551,441 physicians (179,356 generalists and 372,085 specialists) and 150,045 APs. Overall, 10.3% of generalists, 0.7% of specialists, and 4.2% of APs billed for ACP between 2016 and 2017, with small increases among each group (Table 1).

Table 1 Number and Percentage of Providers with ACP Billing, by Year and Provider Type
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For physicians, and especially among generalists, ACP billing was significantly higher among those who participated in an ACO (adjusted odds ratio [aOR], 1.43; 95% CI, 1.38 to 1.48; P < 0.001) or in Meaningful Use (aOR, 1.49; 95% CI, 1.44 to 1.55; P < 0.001), and for those who were in smaller practices, relative to their counterparts (Table 2). In particular, generalists in practices with fewer than 10 physicians (12.6%; 95% CI, 12.3 to 12.9%), with ACO participation (10.3%; 95% CI, 10.1 to 10.5%), and meaningful use participation (10.1%; 95% CI, 9.9 to 10.3%) had the highest adjusted prevalence of ACP billing. Among specialists, those who were foreign trained (0.9%; 95% CI, 0.8 to 1.0%) and those participating in Meaningful Use (0.8%; 95% CI, 0.7 to 0.8%) had the highest adjusted prevalence of ACP billing. Analyses limited to the specialties with the highest prevalence of ACP billing (hematology/oncology, 1.9%, and pulmonary Disease, 1.5%) yielded similar results. For APs, the predicted prevalence of ACP billing was the highest among those in practices with fewer than 10 physicians (5.4%; 95% CI, 5.1 to 5.6%), with ACO participation (4.4%; 95% CI, 4.2 to 4.6%), and those who were female (4.1%; 95% CI, 4.0 to 4.2%).

Table 2 Characteristics of Physicians and Advanced Practitioners and Advance Care Planning Billing
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DISCUSSION

We saw small absolute increases in ACP billing from 2016 to 2017. While generalist physicians accounted for over half of all providers who billed for ACP during this period, APs accounted for 23%. The overall low prevalence of ACP billing masks substantial heterogeneity by provider and practice characteristics. ACO participation and Meaningful Use was associated with higher prevalence of ACP billing among physicians, especially generalists, suggesting that incentives and infrastructure for quality improvement and cost-saving may be conductive to ACP billing. Additionally, providers in small practices across all types had higher prevalence of ACP billing, possibly reflecting closer and longer-term patient-provider relationships in those practices.

Our findings suggest that particular aspects of provider incentives or practice environment may be more conducive to ACP billing. However, the relationships we present are associational, and evidence is still lacking regarding the extent to which providers address ACP without billing for it, or whether ACP billing is associated with improved care quality or lower spending. Further research is needed to address these questions and establish causal mechanisms to inform appropriate incentives and environment for ACP adoption and delivery of preference-concordant care.