Dear Colleagues Letter: Alzheimer’s Disease and Advanced Care Planning

March 2017

Dear Colleagues:

In this month's letter, I'd like to discuss two issues - Alzheimer's disease and advanced care planning.

Alzheimer's disease: Approximately 390,000 New Yorkers have Alzheimer's disease, a number that is expected to rise to 460,000 by 2025. Even though there is an active research agenda, exploring early diagnosis and potential cures, Alzheimer's disease remains a serious concern for New York State, as increasing numbers of patients and their caregivers face the overwhelming challenges associated with the progression of this disease.

Moreover, research shows 11 percent of New Yorkers over age 45 report some type of cognitive decline. And yet, more than half have not discussed their concerns with a health care provider. In addition to fear, patients may be unaware that cognitive decline is not a normal part of aging, or they may be uncertain of what they are experiencing.

A change in Medicare reimbursement this year will make it easier for you to initiate and engage in these conversations and assessments with patients. Billing code G0505 covers a range of services including cognitive evaluation, functional assessment of Activities of Daily Living, evaluation of neuropsychiatric and behavioral symptoms, and advance care planning, including assessment of palliative care needs. The code will enable you to provide a comprehensive set of care planning services. Care planning enables patients and caregivers to learn about treatments, clinical trials and community support services. Studies have shown that those who receive care planning services experience fewer hospitalizations and emergency room visits, and better medication management.

The new billing code will give diagnosed patients time to discuss concerns about cognitive decline with you. The code will also allow you time to perform relevant assessments, and help the person with dementia and their family plan for the future. When a patient does have Alzheimer's or signs of another type of dementia, an honest conversation is important. We should talk to patients about topics ranging from safety and medical treatment to caregiver support and end-of-life planning. We need to openly share the prognosis and link patients to community resources, such as the Alzheimer's Association.

I urge you to take advantage of this new code to open a dialogue with patients you suspect of having Alzheimer's or other forms of dementia. A diagnosis, coupled with solid care planning, can help patients and families navigate the world of dementia care, better manage co-morbid conditions and help caregivers maintain healthy lives. For Continuing Medical Education courses on this topic, please visit: http://www.albany.edu/sph/cphce/phlchron.shtml.

To find community resources in your area, visit: http://www.health.ny.gov/diseases/conditions/dementia/alzheimer/county/. For more information on long-term care, see: https://www.nyconnects.ny.gov/.

Advanced care planning: Whether a patient is healthy or has a life-altering disease, frank discussions about end-of-life care are important. Since January 1, 2016, Medicare and select private insurers have allowed physicians to bill for advanced care planning and end-of-life discussions, including the completion of advanced care planning documents. The new codes (99497 and 99498, respectively) permit you to bill up to 30 minutes per code for such discussions. These codes can be used as needed or whenever a patient has a significant change in health.

These discussions are often difficult, and you may be met with some resistance. As physicians, however, our main goals are to:

  1. Educate and discuss advance care planning documents, which include the Health Care Proxy, the Living Will, and Medical Orders for Life Sustaining Treatment (MOLST).
  2. Increase the level of trust between physician and patient. Subsequent conversations may follow and become easier as trust builds.
  3. Normalize the conversation - many patients feel uncomfortable having end-of-life discussions. By starting the conversation, we can help spread the word that planning can help.
  4. Relieve stress and burden for loved ones at the end of life by promoting early dialogue in and between families.

We have the ability to play a critical role in caring for not only older adults, but New Yorkers of all ages. Your help by using these new codes and encouraging patients to have these important conversations will be of vital help to families facing difficult end-of-life decisions. We should lead these conversations and demonstrate, on a daily basis, the difference that planning can make in people's lives. Additional information and starter kits for having these important conversations can be found at: http://theconversationproject.org/starter-kits/.

Finally, I want to call your attention to the recently-released New York State report on Sepsis Care Improvement Initiative: Hospital Quality Performance. The report, produced by the Department's Office of Quality and Patient Safety, compares quarterly data on the management of sepsis in New York hospitals between 2014 and 2016. It shows a 20 percent increase in the identification of sepsis patients from 10,970 at the onset of the study to 13,126 at its conclusion. In this same timeframe, mortality rates in adults steadily fell from 30.2 percent to 25.4 percent. The new report demonstrates that the protocols adopted in 2013 are having a direct impact on patients.

Thank you, as always, for the work you do to improve the health of New York residents, and for your attention to these important issues.

Sincerely,

Howard A. Zucker, M.D., J.D.
Commissioner of Health