Advance
Care
Planning

A Strategic Imperative for Healthcare Organizations

Enhanced with Latest Research Evidence

Executive Summary

Advance Care Planning (ACP) represents a critical opportunity for healthcare organizations navigating the evolving landscape of value-based care. This enhanced white paper examines the clinical, operational, and financial benefits of implementing a comprehensive ACP program, providing healthcare leaders with actionable strategies and the latest evidence to enhance patient care while realizing significant return on investment.

Key Research Findings:

Research demonstrates that effective ACP programs can lead to:

98.5%

completion rates for Healthcare Power of Attorney documentation

98.5%

completion rates for Healthcare Power of Attorney documentation

52.9%

completion of POLST forms

98.5%

completion rates for Healthcare Power of Attorney documentation

98.5%

completion rates for Healthcare Power of Attorney documentation

98.5%

completion rates for Healthcare Power of Attorney documentation

New Evidence (2023-2024):

  • WellSpan Health's systematic ACP implementation showed patients with completed ACP were less likely to use ICU care despite having higher acuity scores

  • Mayo Clinic Florida demonstrated ACP consultation increased advance directive completion from historic rates of 1% to 65.9% in primary care and from 3% to 28.1% in oncology practices

  • Recent peer-reviewed research published in JAMA Palliative Medicine, American Journal of Managed Care, and NEJM Catalyst confirms ACP leads to more efficient, patient-centered, and cost-effective care

"More than 90 percent of Americans believe it is important to discuss the treatment and palliative options they would choose to pursue if they were to become incapacitated by medical issues in the future."

— The Conversation Project's 2018 National Survey^[1]^

This white paper provides a roadmap for healthcare administrators to implement and scale effective ACP initiatives that align with organizational goals, improve quality metrics, and succeed in value-based care arrangements.

For comprehensive ACP implementation resources, visit Affirm Health's ACP Conversation Guide.^[2]^

Introduction to Advance Care Planning (ACP)

Definition and Purpose of ACP

Advance Care Planning (ACP) is a structured, ongoing process that enables patients and their families to consider and express preferences for future medical care through facilitated discussions intended to be updated as circumstances change. Rather than simply facilitating documentation, ACP identifies high-value opportunities, suggests contextually appropriate next steps, and guides providers toward meaningful actions that align with patient wishes while capturing appropriate value for healthcare organizations.

As noted in Affirm Health's comprehensive guide, "People have the right to make their own decisions regarding their healthcare. In instances where they might be incapable of making these choices, advance directives offer a valuable means to effectively convey their treatment preferences."^[3]^

The primary purpose of ACP is to ensure that:

  • Patients' values, goals, and preferences are known and documented

  • Patients have designated surrogate decision-makers who understand their wishes

  • Medical care aligns with patients' stated preferences

  • Healthcare resources are allocated in accordance with patient values

  • Healthcare organizations can provide truly patient-centered care while optimizing resource utilization

Importance of ACP in Modern Healthcare

Demographic Shifts: The aging of the population means more Americans are living with chronic and serious illnesses, creating a growing need for care planning discussions.

The significance of ACP has grown substantially in recent years, driven by:

Regulatory Support: CMS recognition of ACP services through dedicated billing codes (CPT 99497, 99498) signals the importance of these conversations in high-quality care.

Technological Advances: While medical technology can extend life, it also creates more complex decision points about when interventions align with patient values.

Financial Imperative: Recent systematic reviews indicate that facilitated ACP has the potential to reduce net costs of care near the end of life, with preliminary evidence showing ACP may offset program costs or produce net cost savings. Research demonstrates that ACP is associated with reduced healthcare costs, particularly in the last year of life, with an average savings of $9,500 per patient.

Evolution of Healthcare Delivery Models: The transition from fee-for-service to value-based care incentivizes healthcare organizations to ensure appropriate resource utilization across the care continuum.

Healthcare Cost Context: Global healthcare costs are forecasted to rise by 10.4% in 2025, making cost containment strategies like ACP increasingly critical for healthcare sustainability.

Healthcare organizations now recognize that ACP is not merely a beneficial service but a strategic imperative that simultaneously improves care quality, patient satisfaction, and financial performance.

Clinical and Patient Benefits

Alignment of Care with Patient Values and Goals

A comprehensive systematic review of 132 randomized controlled trials found that ACP interventions significantly improve concordance between preferences for care and delivered care. Studies show that without documented preferences, medical interventions often default to maximum treatment, which may not align with what many patients would choose if properly informed.

Improved Patient Satisfaction and Autonomy

Research consistently demonstrates that patients who engage in ACP report greater satisfaction with their care and have an enhanced sense of autonomy. A facilitated ACP process transforms what could be abstract or uncomfortable discussions into meaningful conversations that empower patients.

As emphasized in Affirm Health's patient education resources, effective ACP conversations help patients understand their healthcare options and feel more confident about their future care decisions.^[4]^

Helps patients articulate what quality of life means to them personally

  • Creates documentation that follows patients across care settings

  • Provides guidance for surrogate decision-makers during times of crisis

  • Reduces family conflict about treatment decisions

  • Increases the likelihood that care will reflect authentic patient choices

Reduction in Unwanted or Non-beneficial Interventions

Research published in the Journal of Palliative Medicine demonstrated that patients with ACP had significantly fewer inpatient admissions (-0.37 admissions) and fewer inpatient days (-3.66 days) compared to matched controls.

Enhanced End-of-life Care Quality

Studies show that patients who have engaged in ACP are more likely to receive care consistent with their wishes and less likely to experience aggressive interventions in their final days that do not improve outcomes or quality of life.

WellSpan Health's analysis of 356 COVID-19 patients showed that those who had completed ACP prior to hospitalization (53%) were less likely to use the ICU despite being older (79 vs. 73 years) and having greater acuity (LACE+ score 71 vs. 65).

Business and Operational Value

Cost Savings and Reduction in Avoidable Utilization

Organizations implementing comprehensive ACP programs consistently demonstrate significant cost savings. Research found that Medicare beneficiaries who participated in ACP had costs that were $9,500 lower per patient in the last year of life compared to matched controls.

Enhanced Clinical Evidence:
A person-centered decision analysis for older adults with end-stage kidney disease found that the cost of implementing nurse-led ACP intervention was $519 per patient, with 68% of ACP patients receiving end-of-life care according to preferences versus only 24% in the control group.

Cost Savings Result From:

  • Emergency department visits reduction

  • Inpatient admissions (-0.37 admissions per patient)

  • Hospital days (-3.66 days per patient)

  • ICU utilization reduction

  • 30-day readmissions decrease

Risk Adjustment and Impact on Value-based Care Models

ACP offers strategic advantages in various value-based care models:

Medicare Shared Savings Program (MSSP): ACP helps identify high-risk patients while reducing unnecessary utilization.

ACO REACH: Benefits from ACP's ability to reduce disparities in care planning and improve appropriate resource utilization.

Medicare Advantage: MA plans benefit from risk adjustment documentation during comprehensive ACP discussions.

The value calculation framework for ACP shows significant potential returns:

  • Basic ACP documentation: 1 point value

  • Healthcare agent designation with contact details: 3 points

  • Specific treatment preference documentation: 5 points

  • POLST/MOLST completion: 10 points

  • Palliative care assessment: 15 points

  • Hospice evaluation/referral: 20 points

These values are further multiplied based on:

  • Mortality risk: High (>30% 12-month): 3x | Medium (10-30% 12-month): 2x | Low (<10% 12-month): 1x

  • Contract type: Full Risk/Capitation: 2x | Shared Savings: 1.5x | Fee-for-Service: 1x

  • Utilization history: High (3+ hospitalizations/ED visits): 1.5x | Standard: 1x

Financial Incentives and ROI for Providers and Payers

Direct Billing Revenue: Medicare reimbursement for ACP services (CPT 99497, 99498) ranges from $80-120 for initial discussions and $70-105 for additional time.

Additional Cost-Effectiveness Evidence: An Australian economic model demonstrated that a nationwide ACP program would be cost-effective compared to usual care.

A comprehensive ROI analysis conducted by OSF HealthCare found that their ACP program generated a 104% return on investment, accounting for all program costs including facilitator training, administration, and direct service delivery.

Billing and Reimbursement

Overview of ACP Billing Codes

Since January 2016, Medicare has provided dedicated billing codes for ACP services, recognizing the value these conversations bring to patient care.

Billing Utilization Trends: CMS data shows notable rise in outpatient ACP billing from 2016 to 2019, though utilization remained under 7.5% across patient subgroups.

For detailed guidance on performing and billing ACP conversations, see Affirm Health's comprehensive resource: "How to Perform and Bill an Advance Care Planning Conversation".^[5]^

 ACP Billing Codes:

  • CPT 99497: Initial 30 minutes of ACP discussion ($80-120 reimbursement)

  • CPT 99498: Each additional 30 minutes ($70-105 reimbursement)

Key billing considerations:

  • No limit on how often ACP can be reported in appropriate circumstances

  • No specific diagnosis restrictions (though documentation should support medical necessity)

  • May be billed on the same day as other evaluation and management services

  • Can be provided via telehealth in many circumstances

Integration with Annual Wellness Visits

As noted in Affirm Health's implementation guide, "Advance Care Planning is an important conversation to have with your patient. Ideally, providers complete an Advance Care Planning discussion during the patient's Medicare Annual Wellness Visit."^[6]^

ACP discussions pair naturally with Medicare Annual Wellness Visits, with no cost-sharing for patients and creating natural opportunities for care planning discussions.

Documentation Requirements and Compliance

Proper documentation is essential for compliant billing of ACP services. Required elements include voluntary consent, time spent, content of discussion, provider involvement, and signatures.

Organizations should implement standardized templates that capture all required elements while remaining adaptable to individual patient circumstances.

Implementation Best Practices

Identifying Eligible Patients and Targeting High-Risk Populations

Successful ACP programs strategically identify patients most likely to benefit, including:

High-Priority Indicators:

  • Age 65+ with multiple chronic conditions

  • Frequent hospitalizations or ED visits

  • Recent diagnosis of serious illness (cancer, organ failure, dementia)

  • Frailty indicators or functional decline

  • Risk prediction tools indicating elevated mortality risk

  • Transition in care setting (e.g., nursing facility admission)

  • Indicators of cognitive decline

  • Dual-eligible populations (Medicare-Medicaid)

Clinical Workflows and
Staff Roles

Effective ACP implementation requires thoughtful workflow design with clear roles for physicians, advanced practice providers, social workers, nurses, and dedicated ACP facilitators.

Implementation Timeline Considerations:

  • Months 1-3: Staff training and workflow development

  • Months 4-6: Pilot implementation in select sites

  • Months 7-12: Gradual rollout across organization

  • Year 2+: Full implementation with continuous quality improvement

Training and Communication Strategies

Quality ACP conversations require specific skills including communication techniques, legal aspects understanding, and cultural competency.

For comprehensive patient education resources to support your ACP implementation efforts, visitAffirm Health's Living Will Resources.^[7]^

Leveraging Technology

Technology plays an increasingly important role through EHR integration, telehealth applications, and decision support tools.

Common Barriers and Solutions

Clinician Discomfort or Lack of Training

Solutions include: Structured communication training, peer mentoring, role-play exercises, and development of specialist ACP facilitators.

Time Constraints and Competing Priorities

Solutions include: Dedicated ACP appointments, team-based approaches, and integration with existing workflows like Annual Wellness Visits.

Patient Reluctance or Misunderstanding

Recent Evidence: A 2024 Johns Hopkins study found that while ACP increased documentation, there was a surprising increase in potentially burdensome end-of-life care, highlighting that documenting preferences alone isn't sufficient without quality conversations.

Family Involvement and Understanding

Engaging designated healthcare advocates is critical to ensure they understand patient wishes and can effectively represent them during health crises.

As healthcare executive Nicole Bradberry observes: "Everything we're doing now is trying to kind of talk to the physicians around it... It's really how do we offer, how do we extend the team, offer services." This insight reflects the importance of providing systems that support physicians rather than expecting them to transform

Case Studies and Evidence

Real-world Examples of ACP Implementation

Current Birmingham Pilot Program:

  • Identifying high-risk patients eligible for remote ACP within physician workflows

  • Conducting thorough ACP conversations (45+ minutes or multiple sessions)

  • Creating pending POLST forms for physician review

  • Demonstrating cost impact through reduced inpatient admissions

 OSF HealthCare ACO Implementation Results:

  • Trained over 150 ACP facilitators

  • Achieved 98.5% completion of Healthcare Power of Attorney

  • Realized $9,500 cost reduction per patient in last year of life

  • Generated 104% return on investment

Clinical Outcomes and Cost Impact Data

Robust Clinical Evidence: A comprehensive systematic review of 132 randomized controlled trials found significant evidence that ACP interventions increase completion of advance directives and concordance between preferences and delivered care.

WellSpan Health System Implementation:

  • Systemwide implementation across 54 ambulatory practices

  • During COVID-19, 53% of patients had completed ACP

  • Those with ACP were less likely to use ICU despite higher acuity

  • Team-based approach with dedicated ACP staff

Mayo Clinic Florida ACP Consultation Impact:

  • Primary care: advance directive completion increased from 1% to 65.9%

  • Oncology: completion increased from 3% to 28.1%

  • Used Honoring Choices model for consultations

 Cost Impact:

  • Average reduction of $9,500 per patient in last year of life

  • Reduced inpatient admissions and hospital days

  • Positive return on investment for program costs

Strategic Recommendations

How to Scale ACP Across a Health System

Phased Approach:

  1. Assessment Phase (Months 1-2): Evaluate current state and readiness

  2. Planning Phase (Months 3-4): Develop implementation strategy

  3. Pilot Phase (Months 5-8): Test approaches in limited settings

  4. Expansion Phase (Months 9-18): Systematic rollout

  5. Sustainability Phase (18+ months): Integration into operations

Aligning ACP with Organizational Goals

ACP initiatives gain traction when connected to quality improvement, value-based care performance, risk management, and financial sustainability goals.

Partnering with External ACP Vendors

Many organizations benefit from partnerships for technology platforms, training resources, and facilitation services.

For organizations seeking comprehensive ACP solutions, Affirm Health offers specialized tools and resources to support systematic implementation efforts.^[8]^

Policy and Regulatory Landscape

CMS Guidelines and Incentives for ACP

CMS has increasingly recognized ACP through reimbursement policies, quality measurement inclusion, and regulatory guidance.

Role of ACP in Health Equity

ACP addresses documented disparities in completion rates across racial and socioeconomic groups while supporting legislative initiatives for expanded access.

Future Trends and Policy Recommendations

The landscape continues evolving with increased digital integration, telehealth expansion, and enhanced standardization across states.

Conclusion

Summary of ACP's Value Proposition

ACP represents a unique opportunity to simultaneously improve patient care and organizational performance while reducing avoidable utilization, improving quality measures, and providing positive ROI.

Call to Action for Health Leaders

The evidence supporting systematic ACP implementation creates an imperative for healthcare leaders to establish ACP as a strategic priority with clear goals, adequate resources, and accountability measures.

Next Steps to Drive Adoption and Impact

Organizations should follow a systematic approach including assessment, planning, pilot implementation, scaling, and sustainability measures.

Enhanced Evidence Base:
Recent studies continue strengthening the evidence, with comprehensive systematic reviews confirming ACP's effectiveness across diverse populations and settings.

 Implementation Timeline: Based on successful implementations:

Months 1-6: Assessment, planning, and initial training

Months 7-12: Pilot implementation and refinement

Months 13-24: Systematic rollout and quality improvement

Years 2-3:
Full implementation and sustainability

Ongoing:
Continuous improvement and adaptation

The Business Case is Clear: With demonstrated cost savings of $9,500 per patient, 104% ROI, improved quality outcomes, and growing regulatory support, ACP implementation represents one of the most compelling opportunities for healthcare organizations.

The Time is Now: With healthcare costs projected to rise 10.4% in 2025, ACP offers a proven strategy to improve care quality while managing costs effectively.

For comprehensive implementation resources and ongoing support, healthcare organizations should leverage available expertise, technology platforms, and evidence-based training programs to ensure successful ACP program development and sustainability.

Visit Affirm Health's comprehensive ACP resources for additional implementation guidance and tools.^[9]^

References

[1] Affirm Health. "Advance Care Planning Conversations - What they are and why they matter." https://www.affirmhealth.com/articles/advance-care-planning-conversations

[2] Affirm Health. "Advance Care Planning Conversations Guide." https://www.affirmhealth.com/articles/advance-care-planning-conversations

[3] Affirm Health. "Living Will Resources." https://www.affirmhealth.com/articles/living-will-resources

[4] Affirm Health. "Educate Your Patients on ACP." https://www.affirmhealth.com/articles/blog-post-title-one-323bl

[5] Affirm Health. "How to Perform and Bill an Advance Care Planning Conversation." https://www.affirmhealth.com/articles/how-to-perform-acp

[6] Affirm Health. "How to Perform and Bill an Advance Care Planning Conversation." https://www.affirmhealth.com/articles/how-to-perform-acp

[7] Affirm Health. "Living Will Resources." https://www.affirmhealth.com/articles/living-will-resources

[8] Affirm Health. "ACP Implementation Resources." https://www.affirmhealth.com/articles

[9] Affirm Health. "Comprehensive ACP Resources." https://www.affirmhealth.com/articles

Academic References

  • Bond, W. F., et al. (2018). Advance care planning in an accountable care organization. Journal of Palliative Medicine, 21(4), 489-502.

  • Systematic review of 132 randomized controlled trials on ACP efficacy

  • WellSpan Health COVID-19 patient outcome analysis

  • Mayo Clinic Florida ACP consultation impact study

  • OSF HealthCare ROI analysis

  • CMS billing utilization trends and policy updates