Advance Care Planning (ACP)

This is a critical development in quality measures. In 2024, The Journal of Healthcare Economics published research reviewing the impact of ACP for 27,000 CMS decedents. The results demonstrated a 17% decrease in cost of care in the last year of life - representing costly interventions that were not imposed on individuals who had the opportunity to decline them (Chen, Paying for advance care planning...). The expansion of ACP to all adults, as proposed by this MUC, provides greater protection for individuals. 

Despite all the great advances in medical care, the death rate remains the same: one per person. As an ER doctor, I've seen too many times how the failure to have completed advance directives has led to confusion and stress for both clinicians and families. In my opinion, every adult should complete an advance directive from age 18 on up with updates periodically. These documents need to be available to clinicians as needed, and clinicians need to learn to honor them. This will improve care, respect personal values, avoid unnecessary and unwanted care, and save money. That's why I support this measure and urge its adoption.

While we support the intent of strengthening advance care planning, we urge CMS to carefully consider how this proposed measure would function in real-world skilled nursing facility settings and whether accountability is appropriately aligned.

1. Attribution and Accountability Misalignment

While the goal of promoting meaningful advance care planning (ACP) is appropriate and supported, the proposed measure risks misaligned accountability for skilled nursing facilities. As written, the measure hinges on ACP documentation by the time of hospital discharge, yet SNFs frequently have no control over whether or how ACP discussions occur in the acute care setting. Holding SNFs accountable for hospital-level documentation creates unintended consequences and does not accurately reflect SNF performance or care quality.

Recommendation(s):

• Attribute the measure solely to the hospital setting or
• Allow SNFs to meet the measure if ACP documentation is present upon SNF admission or completed within a defined post-admission window
• Permit documented patient or family refusal or clinically appropriate deferral, after appropriate discussion, to satisfy measure requirements
• Exclude cases involving short stays, rapid readmissions, or clinically unstable patients

2. Clinically Appropriate Deferral or Refusal of ACP

There are common and appropriate clinical situations in which ACP discussions cannot or do not occur in a short-stay SNF stay. Following sudden, life-altering events such as acute stroke or myocardial infarction, patients and families may decline or defer ACP discussions due to lack of emotional readiness. In these cases, defaulting to full code status is clinically appropriate and patient-centered, yet, despite the requisite discussion, no documented decision may exist by discharge. The absence of documentation in these scenarios reflects respect for patient and family wishes—not a failure of care.

Recommendation(s):

3. Short Stays and Rapid Readmissions

The measure also does not account for brief SNF stays or rapid readmissions shortly after hospital discharge. In these situations, SNFs may not have sufficient time to complete the clinical assessments, interdisciplinary review, and family engagement necessary to conduct a meaningful ACP discussion. As written, these clinically unstable or transitional cases would still negatively impact SNF performance despite being beyond facility control.

Recommendation(s):

4. Patients without representatives who are unable to engage in ACP-related discussions.

The proposed measure also does not account for situations in which patients are admitted to a skilled nursing facility without a family member or legally responsible party and are clinically unable to participate in a meaningful advance care planning discussion. In these cases, facilities appropriately default to full code status to ensure patient safety and compliance with ethical and legal standards. While an ad hoc ethics committee process may occasionally be used to facilitate changes in advance care planning without patient or family involvement, such circumstances are rare and highly case-specific. Absent an explicit exemption, these clinically appropriate situations would result in noncompliance despite the absence of any feasible alternative. 

• Consider creating an exemption or allowable exclusion for patients who lack decision-making capacity and an available surrogate at the time of admission.

Conclusion

Absent these refinements, the measure risks penalizing skilled nursing facilities for clinically appropriate care decisions and circumstances beyond their control, rather than meaningfully improving advance care planning outcomes.

Without appropriate exclusions and flexibility, the measure risks functioning primarily as a documentation compliance metric rather than a true indicator of patient-centered care. This may incentivize premature or perfunctory ACP discussions, increase administrative burden, and expose SNFs to financial and reputational risk unrelated to care quality.

Thank you for your time and consideration. 

• I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

Adult nurse practitioner here- advance care planning has been shown to improve goal-concordant care for patients. it can ease family/caregiver distress and can even contribute to lowering cost of care and length of stay. Thank you for considering!

The John A. Hartford Foundation has supported serious illness care for more than a decade as part of our mission to improve care for older adults. In our support for palliative and end of life care, advance care planning has been an important feature as it aligns with the Age-Friendly Care 4Ms (what Matters, Medication, Mentation, Mobility). Therefore, JAHF sends our support for MUC2025-020 for Advance Care Planning to expand its focus to all adults 18+ for inpatient encounters, to ensure care plan decisions are aligned with what Matters.

I support the proposed Advance Care Planning measure MUC2025-020. Expanding ACP measurement to include adults ages 18 and older and focusing on inpatient encounters recognizes that serious illness can affect individuals of any age. Advance care planning is essential to ensuring that patient preferences are known and respected, particularly during hospitalizations when individuals may be unable to make decisions for themselves.

• I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

As a former palliative care and hospice social worker and the manager of a health-system Advance Care Planning program, I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+  and all adults should have an advance care plan, especially those hospitalized for any reason. ACP is good for all adults and should a standard (though voluntary), not the exception. We have had sucess in offering and completing advance care planning for all adults, regardless of age, across community settings and throughout the health care continuum. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets all adults (18+ age) and is focused on patients in healthcare facilities. Including not only the documentation of ACP forms but documentation of ACP was discussed  to count as ACP measure is critial because having ACP discussion is often more meaningful and useful when the time for end-of-life decision making comes and the patient is not able to speak. All adults should have an advance care plan, especially those hospitalized or admitted to healthcare facility for any reason. 

INELDA supports the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. Thank you for addressing this important need for all.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

•    I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, regardless of their current health status.  This becomes increasingly important with ANY hospitalization.  Normalizing conversations around advance care planning and supporting individuals and their loved ones to engage in the process of advance care planning is crucially important.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. Younger people are particularly at risk as they are more likely to be involved in serious accidents impairing their ability to communicate in an emergency room situation. In any event, all adults should have an advance care plan, especially those hospitalized for any reason. 

   I strongly support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason

I support MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+,  focused on inpatient encounters, where people can be too ill and unable to make decisions for themselves. 

Family Caregiver Alliance, a California based non-profit  working to improve the quality of life for family caregivers and their care recipients, supports the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves.  All adults should have an advance care plan to guide family caregivers and healthcare staff, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

As a physician, I am strongly in favor of programming and services that support ACP.

I see all too often the struggles that patients, families and medical staff encounter when there has not been adequate planning , understanding of the best path forward.

Al Harding MD

As a leader in advance care planning work in Texas (I was the lead physician author of the Texas Advance Directives Act and as Clinical Director of the Office of Clinical Ethics and Palliative Care, my office leads all advance care planning work across Baylor Scott and White Health, a large not-for-profit health care system), I strongly support the addition of MUC2025-020 for Advance Care Planning (ACP). In our system, we have made engagement in serious illness conversation and completion of advance care planning documents a major focus of quality initiatives for years. Because human mortality remains 100% and most deaths are preceded by one or more interactions with organized health care in the final chapter of life, any measure that fosters more, better, and earlier advance care planning is most welcome. MUC2025-020 will first and foremost benefit all patients and their families while secondarily benefiting health care professionals and the organizations they work within.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. 

All adults should have an advance care plan, especially those hospitalized for any reason. As a Palliative Care doctor who sees patients in both inpatient and outpatient settings, I recognize the value of having wishes and preferences documented in the EMR to assist in ongoing discussions about the types of care the patient wants. 

My mom was paralyzed soon after my birth.  I become a doctor to better care for her and understand her illness and also help her at the end of her life.  But if you ask me how many times I talked to my parents about my mom's wishes at the end of life.  Even after I became a doctor, that answer would have been none, until I was forced too. These conversations are difficult, but are so very important.  She was my mom and I her son, but I was not her doctor.  We eventually had these conversations, that I have with my patients every day to know their values and their goals.  I fully support the committees work to help patients and their families with Advance Care Planning (ACP)

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. We as health care providers cannot fully honor a patient's wishes if those wishes have not been made known through an advance care plan. 

As an LPN who has worked in healthcare for over thirty years, and an End of Life Doula who works with adult individuals, I support the addition of MUC2025-020 for Advanced Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason.

I've watched older adults coming into the healthcare system without awareness of the need for ACP, and they are no longer in a position to discuss their options, their wishes, or their desires.  Let's take a positive step forward and begin educating all adults on the importance of ACP and the opportunities it opens up for patient-centered care.  We can and should do better.

Create a website at the government level that links that requires this information be gathered prior to anyone signing up for insurance and updated whenever a change of insurance occurs.  Insurance companies must insure that it is in place when attempting to sign people up for a plan.  Make is searchable by any provider anywhere so once it is on file it can be accessed by anyone with HIPPA clearance relative to the patient.  Let the insurances be responsible for something.  They would prefer to keep the profits, let them foot the bill. 

As an ICU nurse and now acute care nurse practitioner of 35 years, I have seen the devastating results that the absence of an Advance Directive (AD) can cause - increased pain and suffering to the patient, guilt and increased suffering to the family and moral distress to those caring for the patient, especially as the potential for any quality of life wanes and futility waxes. Because of this, I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. I would suggest training be available for those who are patient facing as some of the issues are the discomfort that people experience when broaching the topic of AD. It would be most helpful if forms were portable across all states as well. 

I support the addition of  MUC2025-020 for Advance Care Planning (ACP) because it targets adults 18 and older and focuses on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults, especially those hospitalized for any reason, should have an advance care plan. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I totally support this 

ACP ensures that all people discuss and document their healthcare wishes before a crisis that could lead to end-of-life care.

This improves their quality of life and reduces conflict and moral distress encountered by medical providers and caregivers or family members alike.

The expansion of ACP to all adults 18 years and older is a further benefit, considering that the younger the person, the more unexpected terminal illness and end-of -life decision-making, making the ACP even more important.

As a Palliative care educator teaching undergraduates, I have made it a standard that all my students select and sign a designated healthcare representative form before completing their 100-level course in Palliative care. ACPs are not only for the elderly; the entire healthcare system is bound to benefit from the widespread use of advanced care planning.

Olubunmi Okanlami MD, MBA, FAAP

Chair of Palliative care,

Indiana University, South Bend.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

As a palliative care nurse and  leader in advance care planning work in Michigan (Community Coordinator for Making Choices Michigan for 8 years), I strongly support the addition of MUC2025-020 for Advance Care Planning (ACP). Our non-profit focused on providing free, community-based advance care planning conversations for all Michigan residents, 18+. Our added incentive for younger adults was based on younger adults not having automatic patient advocate representation by a family member after age 18. We also supported the development and passage of the Michigan Physician Order for Scope of Treatment [MI-POST], legalized in 2017. My extensive experience in ICU/trauma care and serious life-limiting illness reinforced the need for well-informed advocates to carry out the wishes of those who cannot speak for themselves. Early conversations when adults are well and/or early in their serious illness diagnosis have the time to make well thought out decisions based on their values and beliefs regarding treatment preferences/goals of care. 

• I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on impatient encounters where people can be so ill as decision making will be difficult for them. All adults should have an advance care plan, especially those hospitalized for any reason.  This measure needs to be added to Medicare programs.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. Thank you. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill, as happens with patients dying of brain cancer, they become unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. 

All adults should have an advance care plan, especially those hospitalized for any reason.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) especially since it as it now includes 18 years and over.

I do think that you consider making sure the people who do not understand  "Advanced Care Planning" have a representative help them. The representative can help grately especially with people who speak a different language.

Also how can you make sure that hospitals and clinics discuss this with every patient?

C-TAC supports this measure as we strongly support advance care planning. In this case, expanding the population to those 18+ recognizes that any adult in the hospital may be seriously ill and that having designated a health care agent and expressing their wishes regarding treatment would be helpful if they were to become too sick to speak for themselves. While states have provisions for a hierarchy of surrogates ,if somene does not have an advance directive, these only narrow it down to groups of people like adult children or siblings rather than individuals who hopefully know the patient's wishes. It is always better to have the patient's input, via an advance care plan, rather than burdening loved ones to make very difficult decisions. And limiting a measure to only those in their 50s or 60s could be seen as ageist. Some patients younger than that can be seriously ill, such as young adults getting cancer treatment, and so would benefit from a system that promotes getting their input regarding their wishes.

 Dear Members of CMS, 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason.

I use as examples my mother-in-law and my aunt, both of whom died in the past 3 months and who only had ACP conversations as a RESULT of my insistence with clinicians who were providing care for them. Both of them had discussed their advance directives with me and had filled out the legal documents. However, both of them did not have clinicians with awareness of or access to those legal documents. I'd like to point out that as an experienced and board certified palliative care nurse, I was deeply upset that I had to serve as the clinical advocate for my dear loved ones when I should have been recieving emotional support for end-stage repeat inpatient hospitalizations. These women were 85 and 92 years old respectively with histories of COPD and heart failure. While I use this most recent and personal example to make a case for MUC2025-020, I am fully aware that on average only around 30% of American adults across age groups have completed either a health care proxy form or advance directive. 

I am available to offer further comment or support. Thank you for the opportunity to provide input on this important policy proposal. 

Best,

Olga Ehrlich, PhD, RN, CHPN

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. Having the ability to discuss advanced care plans and identify decision makers are imperative for all patients.  Most individuals do not have these documents and have not thought to write their wishes down.  Please approve this measure.  Thank you.

We support the goal of promoting advance care planning as a critical component of patient-centered care. However, we have several concerns regarding the feasibility, implementation burden, and care-setting appropriateness of the proposed Advance Care Planning measure as currently specified for hospitals.

First, there are significant information technology and EHR infrastructure challenges associated with the requirement for documentation of an advance care planning discussion resulting in a documented decision in the EHR. Many EHR systems do not currently support a standardized, structured data field that captures both the discussion and the resulting patient decision in a manner that is reliably extractable for electronic measurement. Implementing such functionality may require substantial EHR configuration or vendor development, creating variability in feasibility across organizations.

Additionally, clarification is needed regarding what specific documentation language or structured data elements would be required to satisfy the measure intent. Without standardized verbiage, coded values, or clear technical specifications, hospitals may interpret documentation requirements inconsistently, potentially undermining measure reliability and comparability.

Beyond technical considerations, we note that advance care planning discussions are often best supported through longitudinal clinician–patient relationships, such as those established in primary care or outpatient settings. Further, expectations for advance care planning documentation may not adequately account for patient readiness or population-specific considerations. Initiating advance care planning discussions with certain populations, such as obstetric or delivering patients, or younger patients who may not be emotionally or developmentally prepared for these conversations, can be distressing and may negatively impact patient experience when the hospitalization is unrelated to serious or life-limiting illness.

We encourage CMS to consider whether the proposed measure allows sufficient flexibility to account for care setting, clinical context, and digitization. Providing clearer technical guidance may help ensure the measure promotes meaningful, patient-centered engagement while minimizing unintended burden and negative patient experience.

Support: Suggest stratification by age.

NKF supports the inclusion of an Advance Care Planning measure in the ESRD Quality Incentive Program. Advance care planning is a critically important, patient-centered process for individuals ESRD, who experience high symptom burden, complex treatment decisions, and frequent transitions of care. Ensuring that patients have opportunities to discuss and document their goals, values, and preferences can improve alignment of care with what matters most to patients and their families.

At the same time, NKF encourages CMS to carefully consider feasibility and implementation within dialysis facilities. Conducting meaningful ACP discussions requires time, privacy, and an appropriate clinical environment, conditions that are often difficult to achieve within in-center hemodialysis units, where space is limited and treatment occurs in shared settings. While clinics with individual rooms may be better suited to these discussions, many hemodialysis patients already experience appointment fatigue and may be reluctant to attend additional visits outside of dialysis. CMS should consider flexible pathways for ACP completion, including telehealth options. Additionally, CMS should clarify that not all patients need an ACP.

Concerns with the burden implementing a structured  field in EHRs to capture "documentation of an advance care planning discussion resulting in a documented decision in the EHR" Will CMS provide exact verbiage needed to satisfy this discussion?​ IT feasibility in order to create this field outweighs benefit.

The ASC Quality Collaboration - a non-profit organization representing more than 2,200 ambulatory surgery centers (ASCs) dedicated to advancing high quality, patient-centered care - would like to share the following thoughts regarding the Advance Care Planning (ACP) measure. 

There is no doubt that advance care planning is an important topic. In fact, the Federal government already has long-standing regulations regarding advance directives that ASCs must meet to participate in the Medicare program. These requirements can be found in the Code of Federal Regulations at §416.50(c), titled “Standard: Advance Directives”. There are several stipulations enumerated in this section, which are more comprehensive than the specifications of the Advance Care Planning measure. These stipulations include, but are not limited to, the following:

• The ASC must document whether or not the patient has executed an advance directive in the patient’s medical record for each ASC visit and must place this documentation in a prominent part of the medical record where it can be readily noted by any ASC staff providing clinical services to the patient.
• Prior to the start of the surgical procedure, that ASC must provide the patient with written information on the ASC’s policies on advance directives, a description of any applicable State health and safety laws, and official State advance directive forms (if requested by the patient).
• The ASC must inform the patient of their rights to make informed decisions regarding their care.
• If the ASC transfers a patient with an advance directive to another healthcare facility, the ASC must ensure that a copy of the patient’s advance directive is provided with the medical record documentation sent to that facility.
• The ASC is further required to provide education to its staff concerning the facility’s policies and procedures on advance directives.

It is important to note that these requirements are not limited to Medicare patients but must be met for all those served at the ASC, thus covering the entire population specified by the measure denominator. 

Compliance with these requirements is assured through unannounced on-site surveys (inspections) of ASCs. When deficiencies in the Advance Directive requirements are found, citations are issued and must be addressed by the ASC in an approved plan of correction. Failure to correct deficiencies could put the facility in jeopardy of losing their Medicare certification and therefore their Medicare payments. 

Given that these requirements already exist for ASCs (and for other providers such as hospitals), a separate quality measure is not warranted to supplement the surveys for certification, recertification, and accreditation that are currently in place.

Premier supports the adoption of an Advance Care Planning measure as it could improve end-of-life quality for patients and potentially avoid costly and unnecessary interventions. 

With respect to administration in the Hospital Outpatient Quality Reporting Program (HOQRP), Premier urges CMS to be discerning when developing measure specifications. For example, the measure should exclude patients who only have lab or imaging services completed in an hospital outpatient department.

Additionally, CMS should be mindful of “survey fatigue” if patients are constantly asked about their Advance Care Plan every time they see a new provider or specialist. CMS should consider the sites, circumstances, and programs that are most suitable for this measure.

I strongly support the proposal to adopt this measure .

As a palliative care provider I am very well aware of the need to increase advance care planning for all individuals. This is a quality care and quality of life issues. 

On behalf of Koda Health, we support adoption of MUC2025-020 and appreciate the PRMR Committees’ consideration of a measure that advances person-centered care, interoperability, and alignment with value-based payment objectives.

Advance Care Planning (ACP) is a well-established, evidence-based intervention associated with improved goal-concordant care, reduced utilization of non-beneficial services near the end of life, and improved patient and caregiver experience when implemented in a structured and clinically appropriate manner.

 

Peer-reviewed literature and CMS-aligned program evaluations demonstrate that effective ACP is associated with reductions in total cost of care in the final year of life, driven by avoidance of unwanted or low-value interventions. These findings support the inclusion of ACP as a quality measure across inpatient settings.

In an IRB-approved, independent analysis of a digital ACP program implemented at Houston Methodist, a study currently under peer review for publication, patients who completed ACP demonstrated

• Approximately 19% reduction in total cost of care in the last year of life
• More than $11,000 in savings per patient
• Reductions in terminal hospitalizations, ICU utilization, and inpatient length of stay
• Increased hospice utilization and length of stay
• High patient and family satisfaction, with Net Promoter Scores exceeding 80

These outcomes reflect the impact of structured ACP engagement supported by standardized workflows and interoperable EHR documentation.

Measure Relevance and Design Considerations

MUC2025-020 is appropriately designed to:

• Expand ACP measurement to adults aged 18 and older, recognizing that serious illness and incapacity are not limited to older populations
• Move beyond claims-based approaches to EHR-based documentation, improving accuracy while reducing reporting burden
• Recognize both completed ACP documents and documented discussions resulting in decisions
• Support continuity of care across settings through interoperable data capture

Implementation Considerations

To preserve clinical appropriateness and avoid unintended consequences, CMS should incorporate the following implementation clarifications as the measure advances:

• Documented refusal or deferral
  When a patient or surrogate declines or defers ACP following an appropriate offer and explanation, documented refusal or deferral should be permitted to satisfy measure expectations.
• Lack of decision-making capacity or surrogate availability
  Patients who lack decision-making capacity and do not have an available legally authorized representative at the time ACP is offered should be eligible for an exclusion or exception.
• Clinical instability, short stays, and rapid transitions
  Flexibility should be incorporated for brief inpatient stays, rapid readmissions, or clinically unstable presentations in which ACP cannot reasonably occur by discharge.
• Attribution across care settings
  Clear guidance on accountability across hospitals and post-acute providers would support fair performance assessment and reinforce continuity of care rather than setting-specific penalties.
• Structured and interoperable documentation
  Continued emphasis on standardized EHR data elements is essential to ensure ACP information is accessible and actionable across transitions of care.

These clarifications would improve usability across diverse inpatient and post-acute workflows without increasing reporting burden, while maintaining the intent of the measure.

Advance Care Planning is a high-value intervention that improves care quality, supports patient autonomy, and reduces avoidable utilization. MUC2025-020 appropriately reflects this evidence and provides a scalable mechanism to advance ACP as a standard component of inpatient care. Clear implementation guidance will also support future measure maturation and longitudinal care coordination. We support adoption of this measure and appreciate the opportunity to provide input.

Respectfully submitted,
Koda Health

I am submitting this comment in support of MUC2025-020 as a practicing hospitalist and Chief Medical Officer at Koda Health.

From the perspective of an inpatient clinician, the absence of clear advance care planning (ACP) documentation is a frequent source of uncertainty during hospitalizations—particularly when patients experience acute deterioration or lose decision-making capacity. In these moments, care teams and families are often forced to make high-stakes decisions without guidance on the patient’s preferences.

The proposed measure appropriately emphasizes the importance of ensuring that ACP documentation or documented discussions are available in the electronic health record for hospitalized adults. Expanding the measure to patients aged 18 and older reflects the reality that incapacity due to trauma, acute illness, or sudden events is not limited to older populations.

At the bedside, however, it is equally important that ACP measures preserve clinical judgment and patient autonomy. In routine hospital practice:

• Patients or families may decline or ask to defer ACP discussions, even after appropriate explanation. This often reflects emotional readiness rather than lack of engagement, and documenting deferral is a clinically appropriate outcome.
• Some patients lack decision-making capacity and do not have an available legally authorized representative during the hospitalization. In these situations, clinicians appropriately default to established ethical and legal standards, and performance measurement should account for this reality.
• Short hospital stays, rapid clinical changes, or medical instability may limit the ability to conduct meaning

Finally, I support this measure and encourage its implementation in a way that reflects the practical realities of inpatient care rather than incentivizing documentation for its own sake. The quality of advance care planning should not be judged solely by completion rates, but by whether patient values are thoughtfully explored, respected, and made accessible to future care teams. 

Measures that appropriately account for deferral, lack of decision-making capacity, and clinician judgment will better uphold ethical care delivery while advancing our shared goal: ensuring that care provided in moments of vulnerability truly reflects what matters most to the patient.

Best regards,

Desh Mohan, MD

Koda Health 
 

My name is Megan Cannone, and I am a Licensed Clinical Social Worker with over ten years of experience in end-of-life care and oncology, with a particular focus on young adults living with cancer. I strongly support this bill and the inclusion of advance care planning as a measurable standard of care.

Throughout my career, I have witnessed countless distressing and preventable situations that arise when advance directives are not in place. In the absence of documented advance care planning, patients’ wishes are often unclear during medical crises, leaving families to make decisions under extreme emotional strain and uncertainty. This lack of clarity frequently compounds trauma, grief, and long-term psychological distress for loved ones.

I have also observed that providers may avoid these conversations or unintentionally offer unrealistic expectations, which can create false hope. When a crisis or end-of-life moment occurs, this avoidance leads to greater suffering, confusion, and a sense of betrayal for patients and families alike.

Advance care planning should not be framed as a tool of fear, but rather as one of empowerment, dignity, and self-advocacy. Normalizing and documenting these conversations within inpatient care promotes transparency, honors patient autonomy, and ultimately leads to more compassionate, ethical, and patient-centered care.

As a society and healthcare system, we must do better. This bill represents an important step toward ensuring that honest conversations happen proactively, that patient voices are honored, and that unnecessary suffering is reduced for patients and families during some of the most vulnerable moments of their lives.

Thank you for addressing this important topic. We support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. If there is any way we can be helpful going forward, we'd be happy to assist. 

I support the addition of MUC2025-020 for Advance Care Planning (ACP). It focuses on adults (age 18 and older) and focuses on the inpatient setting, where people can be so ill as to be unable to make decisions for themselves. Based on my experiences with serious illness, all adults should have an advance care plan, especially those hospitalized for any reason. 

National Patient Advocate Foundation enthusiastically supports this new measure that reflects important ACP insights shared by our national network of patients and caregivers with extensive lived experience expertise who are committed to making the healthcare system work for all of us. This measure reinforces accountability for integrating skilled clinical communication and responsive documentation processes that capture patient preferences and priorities as essential aspects of quality care delivery. NPAF shares the view that ACP, as detailed in this measure, is applicable early and frequently over the course of serious, complex and chronic conditions - not restricted to end of life-focused advanced directives - and care planning conversations should be systematized in every care setting as a standard aspect of quality care delivery and accountability to support age 18+ adult patient populations and/or surrogate decisionmakers.  NPAF served as a vital patient insight partner in development and ultimate endorsement of the "heard and understood" patient-reported outcome measure now well-recognized by CMS, and we applaud this ACP approach as another meaningful opportunity to move toward patient-driven measures that matter.  

CMS should allow exclusions for patients with legal guardians who cannot create an ACP, as requiring ACP in these cases is impractical and may create compliance issues. 

Please allow flexibility for timing and exclusions where ACP is clinically inappropriate. Shared accountability with ambulatory care and interoperability guidance for external ACP documents are critical. 

On behalf of Kidney Care Partners (KCP), I want to thank you for providing the opportunity to submit comments on the measures currently under consideration for use in select Centers for Medicare & Medicaid Services (CMS) programs (MUC List). Our comments focus on the three measures related to the Medicare End Stage Renal Disease (ESRD) program. We support the hyperphosphatemia measure and urge the MUC panel not to recommend the Patient Life Goals and Advance Care Planning measures at this time for the reasons described in this letter.

KCP is an alliance of more than 30 members of the kidney care community, including patient advocates, health care professionals, providers, and manufacturers organized to advance policies that support the provision of high-quality care for individuals with chronic kidney disease (CKD), including those living with End-Stage Renal Disease (ESRD). Our mission is to involve patient advocates, care professionals, providers and manufacturers to ensure: 

• Individuals living with kidney diseases receive optimal care;
• Individuals living with kidney diseases are able to live quality lives;
• Dialysis care is readily accessible to all those in need; and
• Research and development lead to enhanced therapies and innovative products, which require sustainable reimbursement.

KCP appreciates that CMS seeks to adopt a consistent measure for advance care planning (ACP) across multiple provider groups. We agree with the intent of the measure. However, the measure as specified does not work practically within the dialysis facility setting. The measure’s numerator specifically references ACP discussion resulting in a documented decision in the electronic health record (EHR) by the time of hospital discharge which does not apply to the dialysis setting. It is unclear how a dialysis facility could even be evaluated on this metric. Moreover, it does not appear that the consensus-based entity has endorsed the measure particularly within the scope of the Medicare ESRD program. Thus, given that the specifications are written for specific hospital situations that cannot be applied in a dialysis facility setting, we urge the MUC panel not to endorse the measure. 

Again, KCP appreciates the opportunity to provide comments on the MUC list. We look forward to working with CMS on this and future quality initiatives to improve outcomes and quality of life for individuals who rely upon the Medicare program for life-sustaining dialysis treatments. Please do not hesitate to reach out if you have questions or would like additional information about KCP’s recommendations.

I enthusiastically support this new measure and appreciate several aspects of its scope: it includes multiple inpatient care settings; it expands the denominator by encouraging goals of care conversations over the life course (not just at the end of life); and it expands the numerator of “what counts” as advance care planning by including ongoing clinical conversations. I would recommend that the definition of a “documented decision” also remain broad. Advance care planning conversations often involve patients expressing their priorities and overall preferences as well as expressing their fears and concerns. This information remains clinically important and can help inform patients’ care, even if a typical decision (e.g., yes/no for a medical procedure) is not made. I would also recommend including the documentation from all interdisciplinary care team members, such as nurses, chaplains, social workers, and case managers, who often have in-depth conversations with patients about what matters most.

Please see the attached comment regarding the ACP measure.

I support the proposed advance care planning measure that spans multiple care settings, and the intent of this measure to jettison our healthcare delivery into a new era of person-centeredness.  It is vitally important that the measure seeks to capture the treatment preferences of all adults 18+ and not just those 65+ since "downstream" expressions of what matters and how a person wants their life to unfold as part of routine ACP decisions would be made prior to, or outside of, critical situations or periods of high stress.  

No more should providers check a box marked Full Code or No Code, no more should admissions or intake personnel ask whether a patient has any type of advance care plan and if they say "yes" mark them as No Code.  Situational context, prognosis, and other factors negate the decades-old check box approach.  The time for modernization of our electronic and manual systems, as well as the processes around advance care planning that needs to inform care, is at hand. 

Further, to ensure that advance care plan decisions are available to medical teams treating the people who are the subjects of those documents, there should be a requirement to make them available across care settings, using standards-based interoperable methods.  One of the many gains of the PACIO project has been to demonstrate repeatedly how CDA and FHIR standards which exist enable the movement of data, not just documents, across sites of care in a vendor-agnostic approach. 

 There should also be a recommendation that copies of original documents are acceptable across jurisdictions, so as to enable those plans to be reviewed, validated and leveraged at any setting that would provide care to use them to inform the care plan that will guide care at that setting.  

Individuals should be able to introduce their own paper documents, in scanned form, to their healthcare eco-system outside of a patient portal that only serves to expand the limitations on access without solving them.  Systems and providers that demonstrate an inherent bias to only those advance care plan decisions created by or added to the available health information by medical professionals, not the individuals themselves who distribute copies of documents when data availability fails, should not limit the potential of this important measure.

To ensure that various advance care plans stored at multiple provider record systems for the same person do not dilute the validity of those documents, which could give medical teams concern about honoring the “wrong” version or document, a national, highly secure document exchange registry that connects HIEs and providers together for this type of important advance care plan decisions is ideal.  One that is robust enough to track meta data including ACP document type, date created, version, and document status such as “current”, “superseded”, and “voided” would ensure that the spirit of the quality measure is feasible and would leverage technology to combat decades-old manual reliance on paper forms.

To ensure that we implement the measure in the spirit in which it was intended, it should be noted that “in the moment” decisions will at times be expressed by the individual or their designee, which medical teams will heed and honor.  Since discordance between documented ACP decisions and verbal decisions may be experienced, the measure should enable clear documentation as to the clinical reasoning when documented decisions are not honored in favor of verbal decisions, so as to substantiate treatment interventions that are not aligned with documented advance care plans.

All individuals have the right to receive the medical treatment and care they document preferences for, based on culture, religion or personal goals for their care journey and life.  Providers have a responsibility to honor what matters to the people they treat, and create treatment or care plans based on the individual's own goals for their care.  People should not be moved through the healthcare system, but should instead move the healthcare system.  Delivery of personalized medicine that discourages unwanted over-treatment and is instead focused on ensuring quality of life as defined by that individual is the goal.  This measure sets a clear path forward, and is a call to action, that we are ready for a responsive personalized healthcare system that individuals can trust, is financially responsible, and aligns the promise of modern medicine with the dreams and hopes of all who want to have a say in what quality of life means to them.

FME believes CMS should only incorporate consensus‑based measures into quality programs, and notes this measure is not endorsed by consensus-based entity. The measure evaluates an advance care planning discussion that must result in a documented decision in the electronic health record by the time of hospital discharge, which does not apply to the dialysis setting because it measures an activity that occurs in the hospital rather than in outpatient dialysis care.

Recommendation: FME recommends that CMS not adopt MUC2025‑020 for dialysis facility quality programs, as the measure is not endorsed and does not reflect activities that occur within the outpatient dialysis setting.

On behalf of the American Heart Association, including the American Stroke Association (Association) and 35 million volunteers and supporters, we appreciate the opportunity to submit comments on MUC2025-020 Advance Care Planning. The Association would support the use of this measure to replace the current Advance Care Plan measure resulting in an expansion of measurement from those aged 65 years and older to all patients 18 years and older.

On behalf of Healthy Aging Martha’s Vineyard (HAMV), we are pleased to submit these comments in support of the U.S. Center for Medicare and Medicaid Services proposed Advance Care Planning measure, MUC2025-30.  We applaud the expansion to target adults 18+ and in in-patient encounters, and are pleased that the regulations encourage hospitals to use ACP documentation as evidenced by any one of the four forms: Health Care Agent, Advance Directive, Portable Medical Orders, or other documentation that an ACP discussion resulting in a documented decision has occurred. 

The proposed measure is a fitting companion to federal legislation in 1989 and 1990, which mandated healthcare facilities to inform patients and residents about their rights to make healthcare decisions and have advance directives.  Action in these years further introduced changes to the Medicare Fee Schedule including billing codes for documented discussions of Advance Care Planning conversations between patients and physicians.

While these reforms were aimed at patients and residents in hospitals and residential care, the vast majority of care today is delivered at home and through community services, where Advance Care Planning may not be “top of mind.” Patient self-determination has to start both earlier in life and earlier in care planning, both to give individuals the rights to express their preferences (which do not, research shows, always align with what their closest relatives think they prefer) but also to ensure that the opportunity is not lost with a sudden and grave illness.

At the same time, we note that an individual’s Advanced Care Planning process is highly personal and ideally should not wait until a decision under stress in the ER setting. HAMV believes that all adults should have an Advance Care Plan, and in our own island community HAMV has produced videos with community volunteers telling their stories about how important they have found this decision-making in their lives. Additionally, we have found that many physicians could benefit from training in how to discuss end-of-life issues with patients most productively, including cross-cultural issues which are currently obstacles to such discussions.  We hope that CMS will consider these issues – beyond the data measurement requirements – in the future. 

The American Hospital Association recognizes that advanced care planning is an important part of ensuring that the care they receive aligns with their goals and values. However, we urge Battelle, the measure steward, and CMS to provide more detailed information on how this measure would be implemented in the many programs for which it is under consideration. The measure was developed and tested at the inpatient and skilled nursing facility level and is specified to include patients who had at least one inpatient encounter during the measurement period; because of this inpatient and institutional focus, it is unclear how the measure would be reported by other facilities, particularly on an outpatient basis (i.e. in the OQR and ASCQR). The supporting documentation does not provide insight into how various facilities could use their EHRs as a data source to inform the measure, and the measure as presented to the PRMR has not been specified for individual settings.
 

The developer’s narrative suggests significant feasibility issues, as structured fields to capture the ACP information do not exist in some EHRs; codes for ACP discussions are not consistently documented; and some items (such as goals, preferences, and priorities) do not exist as standalone items in a structured field. The developer is noted as encouraging facilities “to work with vendors to align data capture with standardized terminology” as a solution to these feasibility issues, which to us suggests that the measure has not yet been sufficiently developed for use outside of the settings for which it was specified. In other words, the measure should be feasible to report and provide meaningful information to providers, CMS, and Medicare beneficiaries without back-end fixes put in place by third parties. 
 

We believe clarity on these issue would be critical to ensuring that measure reporting does not result in duplicative or discordant data collection, with multiple versions of advanced care plans existing across multiple different entities and providers. We hope to hear more during the PRMR discussion of CMS’s perspective on the use of this measure in the various quality reporting programs.

I strongly support the adoption of MUC2025-020, the proposed quality measure assessing documentation of advance care planning (ACP) or ACP discussions for adults. This measure represents an important and timely step toward improving patient-centered, goal-concordant care across health care settings.

Advance care planning is a foundational component of high-quality care, particularly for patients facing serious or life-limiting illness, but also for adults of any age who may experience sudden changes in health status. A robust body of evidence demonstrates that ACP improves alignment between patient values and the care delivered, enhances shared decision-making, reduces decisional burden on families, and supports more appropriate use of health care resources. Despite this evidence, ACP remains inconsistently implemented and documented, particularly during inpatient encounters when clinical decisions are often made under conditions of uncertainty and time pressure. MUC2025-020 addresses this gap directly.

Importantly, this measure aligns with clinical models and research from comprehensive cancer centers, where interdisciplinary approaches to serious illness communication, palliative care integration, and psychosocial support are central to quality care. Research and clinical programs from our Center have consistently emphasized that meaningful conversations about goals, values, and preferences, when conducted early and revisited over time (and not limited to end-of-life conversations only), are associated with better patient and caregiver outcomes, including improved communication, reduced distress, less financial burdens, and care that more closely reflects patient wishes. Embedding ACP as a measurable quality standard reinforces these evidence-based practices.

Additionally, MUC2025-020 reflects ethical principles seen in peer-support and supportive care models, which should be widely used across healthcare in the USA. Peer support through patient, caregiver, and survivorship programs, helps normalize conversations about prognosis, values, and future planning. These environments empower patients to articulate preferences, ask questions, and engage more fully in ACP discussions with clinicians. By incentivizing documentation of ACP conversations, this measure supports the translation of these relational and educational benefits into durable, accessible clinical records that can guide care across settings.

From a systems perspective, MUC2025-020 promotes continuity, transparency, and accountability. Standardized measurement of ACP documentation improves communication among clinicians, reduces the likelihood of unwanted or non-beneficial interventions, and supports value-based care goals. The inclusive age criterion appropriately recognizes that advance care planning is relevant to all adults, not only older populations. 

In summary, MUC2025-020 is well-aligned with current evidence, clinical best practices, and patient-centered care models. Adoption of this measure would meaningfully advance the quality of care by normalizing, measuring, and reinforcing advance care planning as a standard part of patient care. I strongly urge CMS/NQF to support and implement MUC2025-020.

The American Medical Association supports the intent of this measure; however, it is not clear whether it will replace the existing QPP 047: Advance Care Plan or will be another option for reporting. We support continuing to include QPP 047 in the Merit-based Incentive Payment System (MIPS) and encourage CMS to work with its steward to align the measure specifications across both measures. Specifically, the numerator requirements should be consistent, and this new measure should also enable clinicians to receive credit for numerator compliance if there is a cultural or spiritual reason why this conversation cannot occur with a patient, which is currently included in the QPP 047 specifications. 

In addition, we believe that this measure, while important, should be tested at the individual clinician level and across multiple electronic health record systems (EHRs) before its inclusion in MIPS. Currently, the measure was tested at the facility level, and the data element validity was assessed in only one vendor system. Given the complexity of the numerator, evaluation of EHRs’ capabilities to capture the required data elements in additional systems will be necessary, particularly since the initial testing identified some challenges in capturing the required data in discrete fields. 

January 6, 2026

Dear Members of the PRMR committees: 

On behalf of the more than 5,200 members of the American Academy of Hospice and Palliative Medicine (AAHPM), we appreciate the opportunity to provide feedback on the measures under consideration for Centers for Medicare & Medicaid Services (CMS) quality programs. AAHPM is the professional organization for physicians specializing in Hospice and Palliative Medicine. Our membership also includes nurses, social workers, spiritual care providers, pharmacists, and other health professionals deeply committed to improving quality of life for the expanding population of patients facing serious illness as well as their families and caregivers. Together, we strive to advance the field and ensure that patients across all communities and geographies have access to high-quality palliative and hospice care. 

Advance care planning (ACP) is an important component of high-quality serious illness care. We consider ACP as a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.¹Studies show that advance care planning can improve patient and family satisfaction, decrease hospitalization and intensity of treatment near the end of life, increase hospice use and the likelihood of patients dying in their preferred place, and reduce stress, anxiety, and depression in surviving caregivers.  AAHPM therefore supports efforts to promote ACP discussions, and we view the ACP measure (MUC2025-020) as an effective starting point.

Importantly, a critical component of effective ACP is ensuring patients clearly identify a health care agent or, among patients who do not have capacity to engage in ACP discussions, surrogate medical decision-makers. We believe identification of such agents or surrogates should be a priority for patients in inpatient settings. However, we question whether the measure would effectively achieve such a goal, given insufficient attention to the role of the health care agent or surrogate in the numerator logic. For example, the measure should explicitly exclude in-hospital-only and temporary health care surrogate designations from qualifying as valid surrogate decision-makers. Some hospitals use temporary advance directive forms at admission that are framed as identifying an emergency contract rather than a true surrogate decision-maker. Absent this exclusion, facilities may receive credit for the measure without any accountability for effective ACP. Furthermore, efforts should be made to exclude patients who are unrepresented as institutions who care for more unrepresented patients may be penalized inadvertently.  

We also highlight additional limitations that we believe could result in unintended consequences. To begin, we note that the measure does not control for the quality or appropriateness of the ACP discussions, which could inadvertently lead to ACP discussions occurring at inappropriate moments or with insufficiently trained clinicians. Furthermore, Physician Orders for Life-Sustaining Treatment (POLST/MOLST) forms should only count toward the measure when a Do Not Attempt Resuscitation (DNAR) order is in place. Without this limitation, the measure could incentivize routine completion of POLST/MOLST forms for all hospitalized adults, which is neither clinically appropriate nor consistent with best practice. 

AAHPM supports inclusion of an ACP measure in applicable quality programs. However, we urge CMS to appropriately address these concerns prior to proposing adoption in Medicare quality programs to ensure the measure promotes high-quality, patient-centered care.

* * * * * *

Thank you, again, for the opportunity to provide feedback as part of the 2025 PRMR process. Please direct questions or requests for additional information to Katherine Ast, AAHPM Director of Quality and Research, at [email protected]. 

Sincerely,

Kristina Newport, MD FAAHPM, HMDC

Chief Medical Officer, American Academy of Hospice & Palliative Medicine

¹Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017 May;53(5):821-832.e1. doi: 10.1016/j.jpainsymman.2016.12.331. Epub 2017 Jan 3. PMID: 28062339; PMCID: PMC5728651.

I support the addition of MUC2025-020 for Advance Care Planning (ACP). I work in the hospital with Palliative Care. All too often, patients become gravely ill without prior discussions of their preferences around end-of-life decisions. This leaves the proxy decision maker a terrible burden. The layers of grief they experience are significant.  They grieve for the looming loss of their loved one and the decisions they will need to live with that are life and death. When prior Advance Care Planning discussions have happened the proxy still has the burden of grief but it is coupled with peace at knowing what that person wants. Instead of wandering through complex life and death decisions with no real idea of their loved one's preferences, they can peacefully represent their loved one's best interests, knowing that they are doing the right thing for the patient. 

MUC2025-020 – Advance Care Planning (ACP)

This measure intends to determine the percentage of adult patients “with one or more inpatient encounters during the measurement period who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record (EHR) by the time of hospital discharge for at least one hospital encounter during the measurement period.” As rationale for this measure, CMS notes, “This measure aims to advance person-centered care by ensuring that hospitals provide patients and their caregivers the opportunity to discuss their goals of care and/or capture patients’ existing ACP decisions.”

DCI agrees that ACP is essential to patient dignity, medical ethics, and informed decision-making. Moreover, ACP is especially important in dialysis, where treatment is life-sustaining. Many DCI patients already participate in ACP discussions as part of routine care planning, physician visits, and social work support.

However, as currently drafted, the measure appears tailored to hospital-based documentation pathways (e.g., ACP completed “by time of discharge”), which do not translate operationally to outpatient dialysis settings.

To better align the measure with the ESRD environment, we recommend basing it on the percentage of adult ESRD patients who have an ACP document or documentation of an ACP discussion resulting in a documented decision within the survey period.

DCI believes that an appropriate process for dialysis clinics to ensure an appropriate and up-to-date ACP would be:

• ACP should be offered to patients within the first 90 days of starting dialysis;
• ACP should be offered at least once a year.

Committee Members,

Distinguished clinicians, healthcare organizations, patient advocates, and thought leaders have written in support of MUC2025-020 Advance Care Planning (ACP). While we agree with commenters who have proposed limited exclusions and measure implementation clarifications, we also strongly support the addition of MUC2025-020 as an eCQM.

As a healthcare technology company that has spent almost 20 years working to improve ACP data collection, quality, and accessibility, we focus our comments on what is already technologically possible and happening in clinical settings across the entire continuum of care and assure you that the technology and data standards support the adoption and implementation of the proposed eCQM.

Overview – Measure Specification 

Expanding the types of documents available to satisfy the numerator is appropriate, and we would suggest adding mental health advance directives (MHADs) to the list. LOINC document type codes exist to identify each of these documents in EHRs and are widely available to and used by EHR technology vendors. A comprehensive set of HL7 CDA, C-CDA, and FHIR implementation guides make possible the normalized, standardized collection and exchange of the documents themselves and the granular data each document includes, regardless of the care setting. EHR functionality also exists enabling clinicians and other ACP facilitators to record when a patient or surrogate declines to participate in ACP and/or create ACP documents, MHADs, or portable medical orders like POLST, MOLST, and DNR forms.

Meaningfulness – Feasibility

The Committee expresses concerns about missing values for certain ACP data elements across different EHR systems, with specific references to Epic and Cerner. In addition to the data standards discussed above, USCDI contains the data classes and data elements that serve as a baseline for patient care, data access, and IT certification.  Common data points already exist in versions of USCDI that are available in ACP decisions, such as Patient Goals, Care Experience Preference, Treatment Intervention Preference, Advance Directive Observation, and Portable Medical Order.  Systems that enable capture of ACP discussions and the resultant documentation, and that allow a person to decline creating or updating their documents, should already be planning to meet the requirements of USCDI, which dissolves the concern about provider readiness outside of valid workflow modification concerns. The information needed to meet ACP eCQM requirements should be supported by EHRs that meet IT certification criteria as those data elements become required through the existing USCDI process.

As full implementers of the data content and exchange standards relating to personal advance care plans, advance directives, and ePOLST, and from our experience working with EHR vendors across a wide array of care settings, we can confirm that most of these EHR vendors fill the noted gaps by partnering with third-party technology vendors specialized in ACP. When they don’t, their healthcare enterprise customers do so themselves. If EHRs are not including ACP-related data collection and exchange in their workflows, it’s because the vendors feel no requirement, incentive, or market pressure to do so, not because gaps or weaknesses exist in ACP data capture and standardization.

Meaningfulness – Validity, Reliability, and Usability

We agree with the concern expressed by commenters as to whether documenting the existence of an ACP document or portable medical orders alone goes far enough in advancing high-quality, patient-centric, goal-concordant, and order-concordant care. In a clinical setting, if a clinician asks a patient whether they have allergies that could trigger anaphylactic shock, and the patient says “yes,” the clinician doesn’t simply say “thank you” and move on to the next topic. Similarly, checking a box indicating the existence of an ACP document or portable medical orders, without documenting the contents and location of the source document as standardized, interoperable data elements accessible to other sites and providers of care, has never been and will never be sufficient to improve the quality of care or decrease the costs associated with unnecessary and unwanted medical treatments and hospitalizations. Accordingly, we encourage the committee to require implementers of the eCQM to record additional data related to the documents in order to avoid the risk of the measure becoming just another check-the-box exercise that doesn’t move the needle on improving quality or decreasing cost.

Time to Value Realization

We agree with the assertion that it’s unclear how long implementation of the measure will take to improve awareness and/or utilization of ACP. However, 50+ years of history has proven that unless CMS requires or incentivizes healthcare provider organizations and health plans to include ACP as a medical service or a covered benefit, the vast majority of those provider and payer organizations will not take action, regardless of the increasing volume of research and evidence demonstrating the benefits of ACP to every healthcare stakeholder – patients and their families, loved ones, and caregivers; medical teams and first responders providing emergency care in the field who just want to do what’s best for the patient; and the public and private institutions who pay for the care and interventions provided by our healthcare system. 

Technology is not the challenge, behavior change is, and CMS has an opportunity to change behavior for the better by adopting and implementing this eCQM.

Thank you for the opportunity to comment on MUC2025-020. We stand ready to support and collaborate with CMS and other stakeholders in any way you find useful as the measure advances. 

Respectfully submitted,

MyDirectives

Please include quality metrics (not quantitative) that emphasize patient-centeredness in advance care planning documentation.  

It is imperative that hospitals around the country and the world improve their documentation of patient wishes. This helps ensure both that patients get the care they need and that their caregivers do not have to make urgent decisions for them. This is a relatively inexpensive way to improve healthcare in the country.

Having a government mandate that ensures hospitals provide patients and their caregivers the opportunity to discuss their goals of care and capture existing Advance Care Planning (ACP) decisions is crucial for several reasons:

1. Respect for Patient Autonomy

• Patient-Centered Care: Every individual has their own values, preferences, and wishes regarding medical care, especially in critical situations. Ensuring these preferences are discussed and documented gives patients greater control over their healthcare decisions.
• Informed Decisions: Patients and caregivers should have the opportunity to make informed decisions about care options, knowing their treatment preferences are taken into account.

2. Improved Quality of Care

• Tailored Care: When goals of care and ACP decisions are documented, healthcare providers can deliver more personalized, appropriate, and respectful care that aligns with what the patient actually wants. This can lead to better outcomes and a higher level of satisfaction with the healthcare experience.
• Avoiding Unwanted Treatments: Without a clear understanding of a patient's goals and ACP, patients may undergo interventions or treatments they don't want, leading to unnecessary suffering, poor quality of life, or even harm.

3. Avoiding Family Conflict

• Clear Communication: In many cases, families are left to make difficult decisions when a loved one is unable to communicate their wishes. Having an established plan in place reduces confusion, disagreements, or emotional distress among family members, as they have a clear framework for making decisions in line with the patient’s desires.

4. End-of-Life Care and Palliative Care

• Better End-of-Life Planning: For patients facing terminal or life-limiting conditions, having a discussion about their end-of-life preferences ensures they are not subjected to aggressive treatments that may only prolong suffering. Instead, they can opt for palliative care or hospice services, which focus on comfort rather than curative treatment.
• Reduction in Unnecessary Hospitalizations: Clear ACP decisions can guide medical teams to prioritize comfort and quality of life, often reducing the need for frequent or invasive hospitalizations near the end of life.

5. Ethical and Legal Protection

• Clear Documentation: A government mandate would ensure that hospitals document patients’ ACP decisions and goals of care properly, offering legal protection for both patients and healthcare providers. This reduces the risk of medical errors or disputes over treatment plans.
• Compliance with Legal and Ethical Standards: In many jurisdictions, there are legal requirements related to patient rights and the documentation of care preferences, especially when it comes to life-sustaining treatments or Do Not Resuscitate (DNR) orders.

6. Improving Health Equity

• Addressing Gaps in Care: Vulnerable populations, including minorities or those from lower socioeconomic backgrounds, may face more barriers to understanding and discussing care decisions. A government mandate can help ensure that these patients and their caregivers have access to the same opportunities to engage in care planning as others.
• Reducing Disparities: Standardizing ACP discussions ensures that everyone, regardless of background, has the same opportunity to document and voice their preferences, which may reduce healthcare disparities.

7. Reduction in Healthcare Costs

• Reducing Unnecessary Interventions: By clearly understanding patients' goals, hospitals can avoid unnecessary or unwanted treatments, which can reduce healthcare costs significantly. It helps ensure that patients are only receiving treatments that are in line with their preferences and are likely to benefit them.
• Efficient Resource Allocation: With documented care preferences, healthcare resources can be allocated more effectively, focusing on treatments that align with patient goals rather than those that may not offer meaningful benefits.

8. Empowerment of Caregivers

• Caregiver Support: Many caregivers struggle with the pressure of making medical decisions on behalf of loved ones. Having clear, documented discussions about goals of care and ACP helps caregivers feel more confident and supported in fulfilling their role, knowing they are following the patient’s wishes.

In sum, a government mandate requiring hospitals to facilitate these discussions ensures that patients’ wishes are heard, respected, and acted upon in a way that enhances the quality of care, promotes ethical standards, supports caregivers, and reduces both unnecessary suffering and healthcare costs.

Addressing Advance Care Planning is essential not only to save patient and facility resources, but more importantly, to avoid inflicting unnecessary and futile pain and discomfort at the end of life. This initiative should be very useful and ideally in the future can be extrapolated to the outpatient setting as well. If done correctly, hopefully we can increase the number of people who can pass peacefully at home with dignity and surrounded by loved ones. 

Compassion & Choices strongly supports measures that require healthcare facilities to actively support advance care planning as a core component of high-quality, patient-directed care. Advance care planning empowers individuals to reflect on and communicate their values, goals, and preferences for care—especially during serious illness or at the end of life—so that treatment decisions align with what matters most to them.

Too often, patients enter healthcare settings without documented advance directives, leading to fragmented care, unwanted interventions, moral distress for families, and avoidable suffering. Skilled nursing facilities, hospitals, and other care settings are uniquely positioned to initiate and revisit advance care planning conversations, ensure documentation is accessible and transferable across care settings, and honor patient choices consistently.

We support this measure.

ASN recognizes the importance of advance care planning in preparing patients receiving dialysis and their loved ones for end-of-life decisions and supports the concept of a quality measure that encourages this practice. However, ASN has several concerns with the measure as currently specified that need to be addressed before the society could consider offering support. As currently written, ASN cannot support its inclusion in the ESRD QIP.

The measure, as currently specified, has been constructed for and primarily utilized in inpatient hospital settings, as it is triggered by inpatient hospitalizations and requires documentation in the electronic health record by the time of hospital discharge. The key challenge for dialysis facilities is that many do not have interoperable data systems to access these records. In addition, there are no standardized transition of care documentation requirements between inpatient facilities and dialysis facilities, making accurate reporting and implementation of this measure in the ESRD QIP highly challenging.

ASN is concerned that the measure’s patient population is defined as age 18 and older. The MIPS version of this measure sets the age threshold at 65, although these discussions may be relevant for patients with ESRD at earlier ages. Alternatively, rather than using age alone, it may be more appropriate to target the measure to patients with frailty or other markers of advanced illness to ensure the measure is clinically meaningful, patient-centered, and appropriate. 

Aging with Dignity Urges Caution While Supporting the Intention of MUC2025-020

While Aging with Dignity, through its Five Wishes advance care planning (ACP) program, welcomes the expanding emphasis on ACP within CMS, particularly related to the alignment between quality measures and the MAHA initiative, it urges caution regarding MUC2025-020.

More than 43 million Americans in all fifty states have used Aging with Dignity’s Five Wishes program to convey their ACP decisions, and over fifteen thousand organizations (including healthcare providers, community organizations, employers, churches, and faith communities) distribute the Five Wishes advance directive, making it the most widely used ACP program in America. Every year, thousands of nurses, social workers, physicians, chaplains, and other healthcare professionals are trained in the Five Wishes person-centered approach to ACP. 

Five Wishes and Aging with Dignity are eager to support and collaborate with efforts to promote effective ACP.  Based on our 30 years of experience in this field, we are also keenly aware of how past missteps have placed undue burdens on disadvantaged populations – those who have limited familiarity with digital tools, those who have had insufficient access to appropriate healthcare services throughout their lifetimes, those who are alone and unrepresented by healthcare agents or family caregivers, and those who require language translation assistance to understand written and spoken communication. 

The following recommendations would mitigate the concerning elements of the rule described later in the comment:

1. Clarify that ACP is not mandatory for patients by affirming that a patient’s decision not to complete an ACP document is a decision that is rightfully made by the patient, and that documentation of such a decision satisfies the requirements of the rule.
2. Preserve the ability of patients and families to complete the ACP process in the format that is most comfortable and appropriate for them. Requirements for digital documentation on the part of healthcare providers should not limit the options of patients and families who prefer to use paper documents or engage in ACP in a non-digital format.
3. Clarify the roles and responsibilities of the various healthcare settings included in the rule, particularly as it relates to the responsibilities of post-acute providers when the primary measurement is based on the presence of documented ACP decisions in the patient’s EHR before hospital discharge.
4. Expand the scope of clinicians who can be reimbursed for ACP conversations to include nurses, social workers, and chaplains; thereby encouraging more involvement by the members of the interdisciplinary team who are often best prepared to facilitate these discussions.
5. Clarify the characteristics of patients who are appropriate for the various forms of ACP included in the rule, specifically explaining that portable medical orders are only appropriate for certain patients.
6. Encourage training for effective ACP facilitation, particularly for professionals in the post-acute healthcare settings included in the rule, so they are adequately prepared to assist patients and caregivers.
7. If there is a standardized approach to documenting the presence of portable medical orders in the EHR, that same section of the EHR should also include space for the clinician to note the patient’s diagnosis that makes a portable medical order appropriate (like Louisiana’s La-Post document).

We applaud efforts to encourage ACP among all adults, yet we have seen in the past how well-intended regulatory efforts generate unintended consequences if not nuanced appropriately. MUC2025-020 does not yet appropriately reflect these important distinctions, and we would be amenable to providing further recommendations in light of our experience as America’s leading ACP facilitator.

Overly prescriptive implications:

While the measure itself does not require completion of ACP on the part of patients, the uniform tracking and measurement will presumably influence how clinicians approach ACP conversations.  History has shown that if staff are not appropriately trained, these measures will become just another check-box in an electronic health record (EHR), another mere transactional engagement between patients and healthcare staff.  If staff are encouraged to obtain the desired outcome of a documented decision recorded in the EHR – particularly if there are financial incentives for doing so – the leverage used to promote ACP by the regulatory agency through incentivizing providers may create a burden or a perceived mandate on patients.

Individually helpful, but confusing when combined:

It appears that CMS is highlighting four primary positive attributes of the rule.  Each one individually is very positive.  However, introducing them all together as part of the same new rule risks confusion.

1. It expands the measure to include all patients aged 18 years and older (rather than 65+) with one or more inpatient encounters.
2. It broadens the scope of care facilities and situations where ACP is encouraged.
3. It defines the affirmative outcome as the patient having an ACP document or documentation of an ACP discussion resulting in a documented decision in the electronic health record by the time of hospital discharge.
4. It expands the types of documents that may be used as “evidence” of ACP documentation to include durable powers of attorney for healthcare, advance directives, living wills, and portable medical orders (POLST, MOLST, DNR, etc.).

The combination of expanding the target cohort to include all adults over age 18 and expanding the types of acceptable ACP evidence to include portable medical orders may generate confusion.  There has been widespread misunderstanding within the medical community about the intention of portable medical orders (Cole et al. 2023).  POLSTs and similar medical orders are intended only for patients who are seriously ill or have advanced frailty, those whose death in the next year would not be a surprise to the clinician (Polst.org).  Yet, it is common for healthcare providers to assume portable medical orders are appropriate for all patients. They are not. 

The rule must include incentives and/or requirements to appropriately train staff so that the appropriate clinical tools are used for the appropriate patients.  Additionally, any standardization of EHR functionality related to ACP that includes medical orders should include a notation that identifies the underlying condition that clinically indicates appropriateness for a portable medical order.  Louisiana offers a good example with its La-Post document (la-post.org) that includes space for the clinician to note the “patient’s diagnosis of life-limiting illness or irreversible condition.”  Staff training combined with standardizing the requirement to identify the underlying condition that renders a portable medical order appropriate would bring clarity where it is necessary.

The rule should also stipulate that a patient’s decision not to complete an ACP is, in fact, a decision. A facilitated discussion that ends with the patient deciding not to complete a document is still part of an effective ACP process, and facilities should not be penalized or incentivized based on document completion if that is not the patient’s informed decision.

Usability and functionality:

The draft rule requires clarification regarding the roles and responsibilities of various entities. Expanding the type of facilities where ACP is promoted is a good thing.  We worry, however, that some of these facilities that are not accustomed to such interaction will not be prepared or sufficiently trained to engage with patients and caregivers as needed. 

Accountability:

The rule measures a “documented decision in the EHR by the time of hospital discharge.” What then is the role and responsibility of skilled nursing facilities, home care providers, ambulatory surgical centers, and dialysis centers?  Are these non-hospital facilities held accountable for the clinical outcomes that occurred before the patient’s discharge from the hospital (and subsequent admission to a new facility or provider)?

Reimbursement:

We also recognize the continued challenge imposed by the limitation on the types of providers who may facilitate ACP and receive payment or reimbursement.  We strongly encourage CMS to permit reimbursement for ACP conversations facilitated by nurses, social workers, and chaplains.  Particularly if this rule is finalized with a measure based on documentation prior to hospital discharge, it will be important to include members of the interdisciplinary clinical team who are most likely to work directly with patients and caregivers during the time leading up to discharge.

Truly patient-centered:

If a truly patient-centered ACP approach is the goal, any standardization efforts must accommodate flexibility, especially concerning patients who are typically underserved.

For example, people who live in rural areas may have less access to digital ACP services.  Even with access, they may feel more comfortable talking with their caregivers and health care providers and completing a paper document.  While digital solutions may expand access to people living in rural areas, it is equally important not to lose sight of those for whom digital solutions may not be the ideal format for ACP.  Despite our organizational efforts to promote digital solutions to ACP, it is clear that many people still prefer physical documents. 

Others may be reluctant to participate in any discussion, particularly focused on EHR documentation that may be confusing to the patient, which implies less care will be provided. This is a known overall challenge (Lou et al. 2025), especially among those who have struggled to obtain care without insurance.  Any standardized approach to ACP must accommodate the patient’s desire to express other important preferences and goals of care, even if that does not include a designated health care agent or code status.

Still others may be hesitant to complete an ACP process, in print or digitally, that does not include communication in the language they can easily understand (Colley et al. 2022). 

Cole, Connie S., et al. “Factors Influencing Clinician Decision‐Making about POLST Use with Nursing Facility Residents: A Qualitative Study.” Journal of the American Geriatrics Society, vol. 72, no. 4, 21 Dec. 2023, pp. 1199–1206, https://doi.org/10.1111/jgs.18717.

Colley, Alexis, et al. “Missed Opportunities and Health Disparities for Advance Care Planning before Elective Surgery in Older Adults.” JAMA Surgery, vol. 157, no. 10, 12 Oct. 2022, p. e223687, https://doi.org/10.1001/jamasurg.2022.3687.  

Lou, Yifan, et al. “Explaining Racial and Ethnic Disparities in Advance Care Planning: A Decomposition Analysis.” Journal of Pain and Symptom Management, vol. 69, no. 5, 1 Feb. 2025, www.jpsmjournal.com/article/S0885-3924(25)00073-9/abstract, https://doi.org/10.1016/j.jpainsymman.2025.02.014.

SHM would like clarification to ensure that documentation of ACP is inclusive of how these conversations and decisions are stored in a variety of manners. There may not be a DNR “form” per se, but an order may be placed in the electronic medical record (EMR). 

MUC2025-020 – Advance Care Planning (ACP)

Encompass Health appreciates the opportunity to submit comments to the Partnership for Quality Measurement for the 2025 Measures Under Consideration (MUC) list. Our comments specifically focus on MUC2025-020, Advanced Care Planning (ACP), which is being evaluated for several healthcare quality programs including the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP). Encompass Health generally supports the ACP measure given that it is best practice for providers to verify across settings of care when a patient has a documented ACP, such as a designated healthcare agent, advance directive or portable medical orders. 

Before CMS considers adding this measure to any future quality programs, several clarifications and concerns should be addressed. First, the measure developer should clarify what constitutes a documented “ACP discussion” for purposes of satisfying the numerator definition. In order to be billed by physicians, ACP discussions must meet a 16-minute minimum time requirement. Setting a rigid time minimum for purposes of meeting this measure’s requirement in inpatient rehabilitation hospitals would be inappropriate, and we urge the developer to clarify in the measure specifications that any ACP discussion documented in the medical chart, irrespective of length, that results in a documented decision is sufficient to satisfy the numerator definition. Second, as posted on the MUC list, the measure does not have any numerator or denominator exclusions. The developer should create necessary exclusions to the measure, including IRF patients who experience a short stay transfer (within first 3 days of the stay), preventing the patient from being in a setting long enough for an ACP discussion to occur. In both of these instances, IRFs may appear to perform poorly on the measure without a chance to have a qualifying ACP discussion. 

With these modifications and clarifications, the measure would ensure appropriate engagement between providers and patients on ACP in inpatient rehabilitation hospitals. 

Advocate Health appreciates the opportunity to provide feedback on MUC 2025-020, Advance Care Planning (ACP). We support this measure for its emphasis on patient-informed decision-making and its applicability across diverse care settings.

However, we recommend revising the measure’s wording for clarity. The current phrasing—“Documentation that an ACP discussion resulting in a documented decision occurred during the measurement period”—implies that patients must make a decision during the measurement period. This does not reflect real-world advance care planning (ACP) practice. Many patients appropriately choose to defer decisions until after consulting with loved ones or may choose not to express decisions at all.

To align with patient autonomy and the patient-centered goals of ACP, we suggest modifying the language to:
“Documentation that an ACP discussion occurred during the measurement period.”

This approach focuses on confirming and documenting that ACP conversations occurred without requiring a documented decision. It supports shared decision-making, reduces operational risk, and aligns with CMS’s commitment to ensuring that patients’ values and preferences are known, documented, and honored.

Overall, I think that people try to do the “right thing”. When it comes to talking about end of life decisions, we physicians tend to not do a very good job.  In our organization, patients will (ideally) have an ACP note by the third visit.  But the ideal is often missed or poorly done. As an ED physician, I often find myself being the first having  talks with patients with patients who have advanced through multiple lines of therapy.  Your first discussion of this should not be with a stranger hours before you die.  It tears up families who are not expecting to hear that  prognosis. ACLS and intubation cause pain and harm to patients who will often not  recover.  Likewise a ‘robo-note” that does not mention the patients wishes in the event of cardiorespiratory arrest, is useless to me when they come including.

I support the addition of MUC2025-020 for Advance Care Planning (ACP) as it targets adults 18+ and is focused on inpatient encounters, where people can be so ill as to be unable to make decisions for themselves. All adults should have an advance care plan, especially those hospitalized for any reason. 

To the CMS Measures Management System Team,

On behalf of WiserCare, we appreciate the opportunity to provide public comment on the proposed Advance Care Planning quality measure, MUC2025-020, included in the 2025 Measures Under Consideration list. 

Many thanks, 

Laurie Smith, MPH

Jared Drake, MPH

Arul Thangavel, MD

WiserCare, Inc. 

While we support the intent of this measure to promote patient-centered care and ensure goals of care are documented, we have several concerns and recommendations:

Clarification on “Documented Decision”
The measure specifies that ACP documentation must include a “documented decision.” In practice, ACP conversations often result in no decision or a decision to defer. We recommend clarifying whether “no decision” after a documented discussion meets the measure intent, as this reflects patient autonomy.

Risk of Overuse and Patient Burden
There is potential for ACP to be addressed excessively during inpatient stays, which may lead to patient fatigue or confusion. ACP is most effective when integrated thoughtfully into longitudinal care rather than as a checklist item during hospitalization.

Interoperability Challenges
Providers may not know if ACP documentation exists elsewhere due to limited interoperability across EHR systems. Without robust data exchange, duplicative or conflicting documentation could occur. 

Setting Appropriateness
ACP discussions are ideally conducted in outpatient settings by primary care providers (PCPs) who have established relationships with patients. Inpatient encounters may not provide the continuity or context needed for meaningful ACP. Consider aligning this measure with PCP-based workflows.

Quality of Conversations
The measure focuses on documentation but does not address the quality of ACP conversations. Training for clinicians on how to facilitate ACP discussions that align with patient goals is critical. Without this, the measure risks becoming a “check-the-box” exercise.

Bon Secours Mercy Health is supportive of the Advance Care Planning metric but encourages the inclusion of a 3^rd alternate way to satisfy the measure - “Capture of  healthcare decision maker” .  In addition, to ACP documentation and Documentation that an ACP discussion resulting in a documented decision occurred during the measurement period – capture of healthcare decision maker captures the decision maker for those patients who are unable to participate in ACP conversations during  an encounter.

The American Geriatrics Society (AGS) supports MUC2025-020 for Advance Care Planning to be adopted as a quality metric for the Centers for Medicare and Medicaid Services (CMS) programs. We believe that advance care planning is a critically important tool for helping individuals articulate and document their values and preferences as they age to ensure that the care they receive, including end-of-life care, is aligned with what matters to them. The discussions with health professionals, families, care partners, and other designated decision-makers that are a part of advance care planning can help those involved in the patient’s care to understand the patient's treatment preferences should someone else need to make decisions on their behalf. Furthermore, improving data collection and reporting about advance care planning can enhance the quality of care, particularly for older adults and individuals with serious illness.  

National Patient Advocate Foundation enthusiastically supports this new measure that reflects important ACP insights shared by our national network of patients and caregivers with extensive lived experience expertise who are committed to making the healthcare system work for all of us. This measure reinforces accountability for integrating skilled clinical communication and responsive documentation processes that capture patient preferences and priorities as essential aspects of quality care delivery. NPAF shares the view that ACP, as detailed in this measure, is applicable early and frequently over the course of serious, complex and chronic conditions - not restricted to end of life-focused advanced directives - and care planning conversations should be systematized in every care setting as a standard aspect of quality care delivery and accountability to support age 18+ adult patient populations and/or surrogate decisionmakers.  NPAF served as a vital patient insight partner in development and ultimate endorsement of the "heard and understood" patient-reported outcome measure now well-recognized by CMS, and we applaud this ACP approach as another meaningful opportunity to move toward patient-driven measures that matter.

It is important to understand patient wishes.  However, this measure has only been tested on Epic/Cerner.  We are a large, mostly rural health system.  Fewer than 20% o four hospitals have Epic or Cerner. The testing has not been done on a sample that is representative.  Also, if I am reading this correctly, documentation would be in the form of a physician signed order.  When my mom was in multiple  different health settings over a six month period, her registration process or by nurses on admission included these questions, but she never was asked this by physicians.  There is reference in the proposal about under-utilization of ICD codes for ACP, but ACP is not included in any risk-adjustment for inpatient acute care, and applying this code would remove other potential risk variables to inform CMS about the illness burdens of the patients.  I agree that patients need to consider advanced care planning.  I am concerned that the burden and cost for implementation will outweigh the benefits. Thank you. 

Respecting Choices promotes advance care planning (ACP) as the active engagement and support of individuals on their journey through the decision-making process, ensuring that their goals, values, and beliefs guide all clinical decisions. We learned early on that measuring advance directive document completion is not enough to transform the healthcare culture. Real and sustained transformation requires 1) an integrated delivery approach by interprofessional care teams trained to hear and understand an individual's values before describing, in the context of the person and phase of health, how potential treatments might align with their values and goals; and 2) the commitment by care teams and organizations to prioritize the resources for system redesign and implementation to ensure ongoing ACP conversations occur, across care settings and for all phases of health. This new measure will help ensure that more patients express what matters most to them, share this with their health care agent, family, and healthcare team, and receive the care that is best aligned with their values. With this in mind, we support the addition of MUC2025-020 for Advance Care Planning to expand its focus to all adults 18+ for inpatient encounters to receive the benefits of advance care planning. Thank you for your time and consideration.

The AAFP recognizes the importance of Advance Care Planning (ACP) as a critical component of patient-centered care, especially for older adults and those with serious illness. The ACP quality measure, as currently proposed, has meaningful intent and potential to improve patient outcomes. However, its implementation in Medicare payment programs, particularly the MIPS program, requires careful consideration of feasibility, equity, and clinical realities. We support the inclusion of this measure for use in MIPS. However, we strongly encourage CMS to consider the challenges outlined below and work to resolve these issues.

1. Meaningfulness

• Support for Measure Intent: The ACP measure is associated with improved patient care by encouraging discussions and documentation of patients’ goals and preferences. Normalizing ACP conversations for patients 18 and older can help ensure that care aligns with patient wishes before end-of-life situations arise. 

2. Appropriateness of Scale

• Expanded Age Range: The measure’s expansion beyond age 65+ to include all patients 18 years and older broadens its reach but may raise concerns among some clinicians about appropriateness for younger adults who may not be ready for ACP discussions. The evidence for risks, burdens, or harms among different groups is limited, and comfort with ACP varies by age and population. That said, there is growing evidence in support of ACP discussions with patients 18 years and older who have life-threatening conditions.
• Potential Documentation Burden: In the current healthcare ecosystem with health IT interoperability limitations, the measure likely increases documentation burden on clinicians. Structured fields across all EHRs are needed to facilitate easy and standardized documentation. That said, we acknowledge that EHR capabilities are improving, and AI capabilities may help ease documentation burden in the near future.  
• Equity Considerations: Small and rural practices may lack the infrastructure needed to report this measure. In any programs where this measure will be required (rather than optional as it would be in MIPS), CMS should provide technical assistance and financial support to ensure equitable participation. 

3. Feasibility and Implementation Challenges

• EHR and Billing Limitations: Not all EHRs can easily add data fields for ACP documentation. Additionally, not all EHRs can support "auto-dropping" of the necessary codes to meet this measure. Thus, this measure can be difficult and burdensome for clinicians and facilities with EHR systems that do not currently support the necessary data elements.
• Lack of Interoperability: Notification of hospitalizations is not consistent even in clinics with the most advanced EHRs. Private practices and rural health clinics especially may not have infrastructure in place for notifications of patient hospitalizations (admission, discharge, transfer (ADT) notifications). Until ADT, claims, and other discrete data elements are interoperable across all settings, this is a significant barrier to implementation and success on this measure.
• Education and Operationalization: Although the measure can be "met" just by having the conversation and submitting the 1124F codes without choosing a surrogate decision maker or completing an advance care plan, this is not well known across physicians and other health care providers.  Education and training campaigns would need to be completed across all health care systems and practices, and operational details and logistics will have to be carefully drawn out.
• Lack of Adequate Payment: Codes 1124F and 1123F do not generate payment or wRVU for physicians, though the conversations are sometimes lengthy and very personalized to the patient and their family.  
• Multiple Conversations Needed: ACP decisions often require more than one conversation. The measure should recognize that not documenting a decision during a single inpatient admission does not equate to poor care. The AAFP encourages CMS to recognize the complexity of ACP discussions and avoid penalizing clinicians when patients are not ready to make decisions.

4. Time to Value Realization

• Uncertain Impact Timeline: While the measure’s intent is positive, there is no specific plan for measuring near- and long-term impacts as the measure matures. The lower age inclusion also makes value realization more difficult to quantify. 

5. Recommendations for CMS

• Provide Clear Guidance: CMS should issue updated documentation and educational resources to clarify reporting expectations.
• Support Small and Rural Practices: Explore technical assistance and financial support for practices with limited reporting infrastructure.
• Align Across Programs: Ensure the ACP measure is harmonized across federal and private payer programs to reduce duplication and administrative burden.
• Monitor and Update: Continuously monitor the measure’s utility and update as needed to maintain clinical relevance and feasibility.

Conclusion

We appreciate the opportunity to provide the important family physician perspective on this and other measures under consideration. If this becomes a mandatory measure in the Hospital Inpatient Quality Report Program (IQR) as it is being proposed, then we support the inclusion of it as a measure in MIPS as well. That said, we encourage CMS to carefully consider our insight and suggestions to ensure meaningful, feasible, and equitable implementation. Ongoing evaluation and support will be essential to maximize the measure’s positive impact on patient care.

I support the addition of MUC2025-020 for Advance Care Planning (ACP), as it appropriately targets adults age 18 and older and focuses on inpatient encounters—settings in which patients may be too ill to make decisions for themselves. All adults should have an advance care plan, particularly those who are hospitalized for any reason.

Please see attached.

Any opportunity to interact and assess patients end of life wishes should be encouraged.  Prior to a surgical procedure, health care providers should be confident in the event of an unexpected poor outcome. 

This measure appears reasonable and aligns  with ongoing efforts in Kansas to reduce HAI/AR to improve care quality and patient safety. All patients, no matter what the care setting, are at risk for life altering complications.  The Advance Care Planning document ensures the facility knows what to do if severe complications occur.