The Centers for Medicare and Medicaid Services (CMS) released the 2016 Medicare Physician Fee Schedule on October 30, 2015. For the first time, two new CPT codes are included to reimburse for advance care planning.

The decision by CMS to approve payment for end-of-life counseling affirms advance care planning is a critical component of clinical practice. Additionally, the value of thoughtful advance care planning discussions between patients and clinicians is recognized. This is a vital step in ensuring person-centered care. Medical decisions should be based on the individual’s values, beliefs and goals for care that in turn drive the choice of interventions.

Shared medical decision-making must be well informed and cannot be presumed. With the increasing diversity of our population, as well as clinicians and caregivers, there is only one way to know “what matters most” to the person. You must ask the person. This decision supports the National POLST Paradigm Program and New York’s MOLST and eMOLST.

CMS will begin reimbursing for these conversations starting January 1, 2016. The two advance care planning codes are:

• 99497 for an initial 30 minute voluntary advance care planning consultation (Final RVU 1.5)

• 99498 as an add-on code for additional 30 minute time blocks needed (Final RVU 1.4)

New York has been a leader in advance care planning and supports the Institute of Medicine’s Report, Dying in America recommendation that encourages “financial incentives for improved shared decision making and advance care planning that reduces the utilization of unnecessary medical services and those not consistent with a patient’s goals for care.” The actions taken by CMS align with this recommendation and should be followed by other insurers.

The CMS decision is applauded by CompassionAndSupport.org, the MOLST Statewide Implementation Team and the National Healthcare Decisions Day (NHDD) NYS Coalition. Support for the decision was provided during the comment period. Read the letter of support.

For additional information, view the Advance Care Planning code section of the final rule.

The value of advance care planning discussions for the seriously ill person and family is illustrated by Flora’s story. Begin by ensuring everyone understands the current health status and prognosis. Start with simple questions and listen carefully to what matters most to the person. Goals for care that reflect the person’s values, beliefs and what makes life worth living drive the choice of interventions.

MOLST is a communication process that emphasizes shared decision making and follows the 8-Step MOLST protocol. The result is a set of medical orders that reflect patient preferences for life-sustaining treatment the person wishes to receive and avoid in an emergency. MOLST aligns with the National POLST Paradigm that has established core requirements.

Emma Fattakhov, MD serves as the Medical Director of Hospice and Palliative Medicine at Orange Regional Medical Center (ORMC) in Middletown, NY, sixty miles north of New York City. ORMC is part of the Greater Hudson Valley Health System, a not-for-profit health system that provides healthcare to nearly 450,000 residents. She is the eMOLST physician champion for ORMC and Orange County.

As medical director, one of Dr. Fattakhov’s first objectives was to incorporate eMOLST into her hospital’s workflow. This turned out to be a more formidable task than she originally expected. With the support of the eMOLST Program Director and Administrator, the department cut through a handful of red tape and instituted the use of eMOLST into the palliative service a year ago. The hospital medical staff has found eMOLST to be invaluable in patient care.

As the palliative care department uses eMOLST increasingly, Dr. Fattakhov has made suggestions to improve the clinician experience. As a result, she has made strong contributions to the enhancement of the eMOLST web-based application. She is a strong example of how a single physician champion can contribute to the increased adoption, integration and improvement of the eMOLST platform.

Dr. Fattakhov is board certified in geriatrics, hospice and palliative medicine. She began her medical career in obstetrics and gynecology in Novgorod Russia.

“Strong introductions and conclusions are essential for a meaningful life. I resuscitated countless lives as an emergency physician in Israel; many were never given an opportunity to have meaningful discussions. Now, in the United States as a palliative care physician, I help my patients to take control and write their own conclusions.”

By PATRICIA A. BOMBA, MD, FACP

Professionally and personally, I support the decision by CMS to reimburse for advance care planning conversations. Doctors should help initiate discussions with their patients about such decisions. This is an important step to ensure individuals receive the treatments they wish to receive and those they wish to avoid.

Equally important to having a discussion with your physician and other clinicians is to have a conversation with your family. Advance care planning should begin early. Choose the person you trust to make medical decisions if you lose the ability to make medical decisions and share your personal values, beliefs and what matters most with your family and “family by choice.”

Advance care planning is a gift to yourself and your family. What better time to start a conversation than at Thanksgiving when your family gathers for the holidays.

In our family, we have a Thanksgiving tradition dating back to 1992 that has nothing to do with food or football, but rather personal beliefs, values and expectations. It’s our annual family discussion of issues related to Advance Care Planning. I encourage every family to embrace this Thanksgiving tradition. These Thanksgiving discussions helped my family and I honor my mom’s wishes at the end of life.

Years ago my family started this tradition on Thanksgiving because it’s an American holiday that just about everyone celebrates, attracting family members from far and wide. While at first you might think it’s morbid to discuss such issues at a festive gathering, we’ve found sharing our wishes for end-of-life care actually brings us closer. We each gain peace of mind knowing our own wishes will be understood and honored in the event we can’t speak for ourselves. In our family,

“No pumpkin pie, until you tell me how you want to live until you die.”

After the dinner dishes are cleared, the adults in our family stay at the table and talk about what matters most in our lives. We review our advance directives to make sure they reflect our current feelings. We have blank forms handy in case new documents need to be completed and witnessed.

As a medical doctor and health plan administrator with an expertise in palliative care and end-of-life issues, I’m especially passionate about Advance Care Planning. I recommend that everyone 18 and older complete advance directives and keep them on file with their physician, their lawyer and most importantly, their loved ones.

Please share my family’s Thanksgiving tradition!