What’s the Impact of Advance Care Planning in Health Equity?

Racial and ethnic minorities engage in less advance care planning and hospice utilization than Non-Hispanic Whites. Closing the gap between White and other racial and ethnic minority populations could result in better patient outcomes and an estimated $350 million in annual cost savings.

Research tells us several factors contribute to these racial disparities, including:

• Distrust of physicians and the medical system,
• Previous negative experiences with a loved one’s end-of-life care,
• Lack of knowledge of advance care planning options,
• Limited access to health care and advance care planning resources, and
• Personal preference for aggressive life-prolonging care.

Annually, Medicare spends about 20% more on Black and Hispanic population than their White counterparts in the last year of life. That is because minorities were more likely to experience higher cost, potentially preventable medical encounters including admission to the intensive care unit (ICU), resuscitation and cardiac conversion, mechanical ventilation, and gastrostomy for artificial nutrition.

In fact, a recent study of advance care planning and treatment intensity before death by hospitalized COVID 19 patients found significant differences in care patterns that would contribute to higher expenses and potentially more stressful patient experience for minority populations. As shown in the table, people of color may opt for heroics more often, still less than a third of all patients want that. In the absence of ACP documents and portable medical orders, heroics will be performed.

Right to Choose, Change, and Be Heard

We believe the point of advance care planning is to allow patients and members, regardless of race and ethnicity the:

• Right to Choose. Express what they value and have a voice in their care. It’s their right to choose the amount of life sustaining treatment they want in a given scenario.
• Right to Change. Periodically revisit and update their medical goals, treatment priorities, and care preference to reflect changing circumstances.
• Right to be Heard. Access their advance directive information anytime, anywhere, across the healthcare continuum so loved ones and medical teams understand and can honor their wishes.

When done well ACP conversations allow everyone to understand their options including programs like the Medical Care Choices Model (MCCM). This pilot program for terminal and seriously ill patients provides those who are afraid or not ready for hospice care continued access to concurrent curative care.

Launched in 2016 and extended through December 2021, MCCM has been shown to improve quality and patient satisfaction, keep patients in their homes, and reduce costs. The MCCM total net cost of care was 14% less – a $7,254 savings per beneficiary – largely due to fewer hospitalizations and ER visits.

According to CMS, hospitalized participants spent fewer days in the ICU and had shorter stay. Further, they also were more likely to utilize the Medicare Hospice Benefit. A reported 83% of Medicare fee-for-service enrollees eventually transitioned out of MCCM and into traditional hospice, which accounted for nearly 70% of the savings.

Given racial and ethnic minorities propensity for more life supporting treatments, the option to pursue both palliative and curative care would allow those with serious illness to opt into hospice care at their own pace and as they become more knowledgeable of their options. Flexible, digital advance care planning supports patient and member rights.

Just Make An Offer

While there are some inconsistencies, in most studies, compared to Whites, African Americans, Hispanics, and Asians are less knowledgeable about advance directives and less likely to complete them. Here are some advance care planning engagement inequities:

• Blacks were approximately three times more likely than Whites to state that they had never thought about completing ACP.
• Hispanics were two times more likely than Blacks and eight times more likely than Whites to state that they had never heard of ACP and were unaware of the issue.
• Whites were approximately 20% more likely than Blacks and 40% more likely than Hispanics to report that they had decided to complete ACP.
• Whites are two to three times more likely to complete advance care planning than African Americans and Hispanics.

Yet, all survey respondents, regardless of race or ethnicity, reported they would be more likely to engage in advance care planning if their physician, loved ones, or best friend asked them to. About 60% of respondents who had not engaged in advance care planning reported that they would do so if their health-care provider recommended it. But 41% were unsure if their health-care provider would recommend advance care planning.

The most effective methods of to improve completing advance directives include:

• Building awareness of your advance care planning benefit through direct mail, email, and text campaigns.
• Collaborative communication between patients and providers over several office visits.
• Repeated discussions about updating advance directives to reflect the patient’s stage in life.

Closing Hospice Utilization Gap

Increasing hospice utilization amongst minority populations represents a tremendous opportunity to honor patient goals and values, while potentially reducing medical expenditures. In their “Closing the Gap in Hospice Utilization for the Minority Medicare Population” article, M. Courtney Hughes and Erin Vernon estimated that raising the percentage of hospice beneficiaries in the minority community to that of their White counterparts could result in a $270 million cost savings.

We have updated their 2017 analysis to 2019. Since then, the total Medicare beneficiaries increased by 11 million to 61.5 million. Likewise, the number of Hospice beneficiaries grew from 1.49 million in 2017 to 1.61 million in 2019. Over the same period, the ratio of hospice enrollees to Medicare beneficiaries remained relatively unchanged at 2.6%. A good way to increase this ratio is to engage more racial and ethnic minorities in advance care planning discussions that educate them on the benefits of programs like MCCM that combine hospice, palliative, and curative care services.

So, what would happen if we moved the needle on offering advance care planning and those initiatives resulted in higher hospice and palliative care utilization? A Medicare savings north of $350 million as shown table.

Wondering What the Hospice Benefit Savings Could be for Your Organization?

Here is the formula.

1. Medicare Beneficiaries. Estimate the total number of Medicare beneficiaries in your population by race and ethnicity.
2. Hospice Beneficiaries. Calculate the total number of Medicare Beneficiaries enrolled in Hospice by race and ethnicity.
3. Optimal Hospice Utilization Percentage. Determine the optimal percentage of your Medicare population that would benefit from Hospice utilization. In this example the segment with the highest utilization was selected as the target, which was the 2.89% for White Medicare beneficiaries. But you could also select a different target for each racial and ethnic segment.
4. Target Number of People Benefiting from Hospice. Multiply the Medicare Beneficiaries of a given racial or ethnic segment by the optimal Hospice utilization percentage.
5. Optimal Increase in Number of Beneficiaries Enrolled in Hospice. Subtract the existing number of Hospice Beneficiaries in that segment to arrive at the additional number of beneficiaries that would have to enroll in Hospice Benefit to achieve the optimal Hospice utilization.
6. Potential Hospice Care Savings. To approximate the annual benefit for hospice enrollment, multiply the Optimal Increase in the Number of Hospice Beneficiaries Enrolled in Hospice by the estimated savings per enrollee of $2,105.

((Medicare Beneficiaries x Desired Hospice Beneficiary Ratio) – Current Hospice Enrollees) x Annual Estimated Hospice Savings

Or as calculated for Blacks in the table above

((6,396,000 x 2.89)-133,037) x $2,105 = $109,054,998

These figures represent the entire Medicare Beneficiary population. But what would the potential hospice utilization savings be for the average Accountable Care Organization? The estimated annual savings would be $130,000 for enrolling an additional 62 minority patients a year or 5 patients a month.

Advance Care Planning Tools To Achieve Health Equity

Today’s technology support’s everyone’s right to choose, change, and be heard. Readily available digital advance care planning tools help democratize advance care planning for your whole population.

More and more healthcare payers and providers like you that are committed to health equity leverage the ADVault solution suite to support their advance care planning initiatives. Here’s six reasons why.

1. Achievability. Current users have increased advance care planning completion rates from 35% to over 50% with structured, sustained, educational campaigns and MyDirectives invitations.
2. Affordability. Select modular bundles to meet your specific user roles and avoid paying for functionality you don’t need at a small fraction of what competitors charge.
3. Flexibility. Create new or upload existing ACP documents and portable medical orders. Patients and members easily access their accounts via the Internet to modify choices as circumstances change.
4. Clarity. Summary for Physicians provides a quick snapshot of patient decisions for emergency response. Patient video recorded wishes enhance surrogate and medical team understanding.
5. Accessibility. Real connection with every EHR in the healthcare ecosystem that doesn’t require a heavy technology lift and meets industry data exchange interoperability standards.
6. Measurability. Automatic tracking of time spent and activities completed to systematically produce compliance reporting, as well as real-time performance dashboard analytics for actionable business insights that support management decision-making.

We invite you to explore all our ACP tools or schedule a demo to see for yourself how ADVault helps healthcare payers and provider fulfill the promise of health equity.