Medicare Expanded Coverage of Voluntary Advance Care Planning

From the November 29, 2010 Federal Register, 75 Fed. Reg. 73169, 73406.

Comment: We received a number of comments from physicians, health
care providers, and others urging us to add voluntary advance care
planning as an element to the definitions of both the ``first annual
wellness visit'' and the ``subsequent annual wellness visit.'' They
base their recommendation upon a number of recent research studies, and
the inclusion by statute of a similar element in the existing initial
preventive physical examination (IPPE) benefit. One commenter noted
that ``the new wellness visit was wisely designed to build on the
initial preventive physical exam, providing an ongoing, systematic
focus on wellness and prevention by harmonizing Medicare services into
a coordinated benefit.'' Another commenter stated that ``the AWV
provides an appropriate setting for providers to initiate voluntary
conversations about future care wishes, as they counsel beneficiaries
on other aspects of their health and achieving their personal health
goals.'' The commenter added that the ``care plans discussed in the
'Welcome to Medicare visit' should not be frozen in time, but revisited
as an important component of patient wellness.''

Response: We agree that voluntary advance care planning should be
added as an element of the definitions of both the ``first annual
wellness visit'' and the ``subsequent annual wellness visit'' based on
the evidence described below, and the inclusion of a similar element in
the IPPE benefit (also referred to as the Welcome to Medicare visit),
since January 1, 2009. We believe that this will help the physician to
better align the personal prevention plan services with the patient's
personal priorities and goals.

Recently, Detering and colleagues (British Medical Journal 2010;
340:c1345) reported that ``advance care planning improves end of life
care and patient and family satisfaction and reduces stress, anxiety,
and depression in surviving relatives.'' Silveira and colleagues (New
England Journal of Medicine 2010; 362:1211-8) reported that ``data
suggest that most elderly patients would welcome these discussions.''
Lastly, a study by Fischer and colleagues (Journal of the American
Geriatric Society 2010; 58:400-401) found ``no evidence that these
(advance directive) discussions or completing an advance directive lead
to harm.''

Based on the available evidence and other relevant information, we
are adding to the final regulation a definition of the term ``voluntary
advance care planning'' to read as follows:
    ``Voluntary advance care planning'' means, for purposes of this
section, verbal or written information regarding the following areas:
    (1) An individual's ability to prepare an advance directive in the
case where an injury or illness causes the individual to be unable to
make health care decisions.
    (2) Whether or not the physician is willing to follow the
individual's wishes as expressed in an advance directive.
    This definition is based on the definition of ``end-of-life
planning'', which is included as an element of the IPPE as described in
section 1861(ww)(3) of the Act. Thus, the addition of ``voluntary
advance care planning'' to the AWVs extends to those visits a similar
element to the one already in the one-time IPPE.
    We are also revising the definitions of the terms ``First annual
wellness visit'' and ``Subsequent annual wellness visit'' by inserting
a new element (ix) to the definition of the term ``first annual
wellness visit'' and a new element (vii) to the definition of the term
``subsequent annual wellness visit'' in Sec.  410.15 (a) of the final
regulation text that would read as follows: ``Voluntary advance care
planning as that term is defined in this section upon agreement with
the individual.''