Taking time to plan and document a loved one’s preferences for medical treatment and end-of-life care is of utmost importance. It helps respect and communicate their wishes to doctors while reducing unnecessary costs and anxiety. Currently, there is no federal policy mandating the completion of an Advance Healthcare Directive (AHCD), yet a significant portion of Medicare beneficiaries lack one. This article explores the need for such a directive and presents a comprehensive plan to address the issue.

Empowering Medicare Beneficiaries with Clear End-of-Life Care Preferences

Understanding the Significance of AHCD

AHCDs play a crucial role in ensuring that an individual's healthcare wishes are respected in medical emergencies or at the end of life. They typically include identifying a healthcare proxy and a living will, which details the treatments an individual wants to receive. Other complementary documents also help communicate treatment wishes. With the aging population, addressing end-of-life care challenges becomes increasingly urgent. Research shows that patients with ACPs are less likely to receive unwanted treatments and are more likely to receive comfort-focused care.

Historically, federal policies like the Patient Self-Determination Act have emphasized the importance of patient decision-making rights. However, despite these efforts and the availability of CMS provider reimbursement codes, there are still many barriers to completing AHCDs. Medicare beneficiaries often face cultural, religious, financial, and mental health reasons for avoiding these conversations. Additionally, the cost of completing an AHCD and the lack of uniformity in AHCDs across states pose challenges.

The Medicare Advance Healthcare Directive Enrollment Initiative

CMS should launch the Medicare Advance Healthcare Directive Enrollment (MAHDE) Initiative to support all Medicare beneficiaries aged 65 and older. This initiative focuses on four interventions.

Streamline the Process

During open enrollment through Medicare.gov or an alternative CMS-approved secure ACP digital platform, beneficiaries can complete an electronic AHCD and renew it annually at no extra cost. User-friendly tools and resources are provided to guide beneficiaries through the process. Some states are also integrating electronic ACP completion into healthcare enrollment processes.

An annual electronic renewal process allows beneficiaries to review and update their selections. It also provides educational opportunities around end-of-life care. The electronic enhancements ensure that AHCDs are legally compliant and accessible across different states and health systems.

Remove Barriers to Access

CMS should remove the deductible and 20% coinsurance for voluntary ACP services with a physician or other qualified health professional. This would encourage more beneficiaries to complete their AHCDs. Additionally, continued health provider education and partnerships with organizations like The Conversation Project and Evolent can support ACP discussions.

Internal studies have shown that these enhancements can lead to significant savings in the final months of life and potential Medicare spending reductions.

Ensure Electronic Accessibility

CMS should integrate the Medicare.gov AHCD storage system or an alternative CMS-approved secure ACP digital platform with existing electronic health records (EHRs). This would prevent AHCDs from being misplaced and make them easily accessible across different healthcare systems.

External add-ons can be used to connect EHRs with AHCD storage systems, ensuring that Medicare beneficiaries' end-of-life care preferences are consistently honored.

Provide Financial Incentives

CMS should offer financial incentives like tax credits, reduced copayments, and prescription rebates for completing an AHCD. With Medicare's increasing costs, these incentives can provide financial relief to beneficiaries and encourage them to complete their AHCDs.

Medicare Supplemental Insurance can also help cover some of these costs, but additional financial support is needed to make AHCD completion more accessible.

Encourage Expansion of the NCQA's ACP HEDIS Measure

The MAHDE Initiative should be coupled with the expansion of the HEDIS measure to include all Medicare Advantage beneficiaries aged 65 and older. This would embed ACP into standard patient care and incentivize health plans to prioritize ACP.

By taking these steps, CMS can empower patients to engage in ACP and reduce medical costs nationwide. Starting with the Medicare population aged 65 and older can pave the way for expanding ACP efforts to other high-need groups and the general population.

Conclusion:When patients and their families are clear on their goals of care, it is much easier for medical staff to navigate crises. The MAHDE Initiative is a feasible way to support ACP and redesign the healthcare system. By educating patients and families about their options and providing the necessary tools and incentives, we can create a more patient-centered healthcare environment.

In an era where millions of Americans face limited access to high-quality healthcare, artificial intelligence (AI) holds tremendous potential. It enables remote diagnostics, boosts efficiency in public health interventions, and aids clinical decision-making in low-resource settings. However, the private sector's innovation might be widening existing disparities by training on homogeneous datasets and benefiting high socioeconomic status populations.

Unleashing AI's Potential for Medicaid Recipients

Addressing the Disparity Gap

In 2022, the US spent a whopping $4.5 trillion on healthcare, accounting for 17.3% of total GDP. Despite the high spending, outcomes are worse, with lower life expectancy and higher death rates. The 80 million low-income Americans on Medicaid have the least access to healthcare and often face below-average health outcomes. AI has the power to transform healthcare, but private-sector-driven innovation exacerbates inequities. For example, until January 2023, the kidney transplant prioritization model ranked Black patients lower. AI models are more complex and difficult to understand, increasing the likelihood of biases. Startups also focus on more lucrative markets, leaving marginalized populations behind. The Federal Government can bridge this gap. The Center for Medicare and Medicaid Innovation (CMMI) should launch the AI for Medicaid (AIM) Initiative to incentivize and pilot novel AI tools for Medicaid recipients.

The AIM Initiative - A Path Forward

Guided by the former Medicaid Innovation Accelerator Program and relevant executive orders, the AIM Initiative will encourage private-sector partnerships with state Medicaid programs. It aims to lower costs and improve care delivery for rural and low-income populations. Precedents in other countries show early success. In 2023, the UK's NHS partnered with Deep Medical to pilot AI software, saving over $30M annually.

Plan of Action

CMMI will launch and operate the AIM Initiative within the Department of Health and Human Services. $20M from the annual budget will be allocated. State Medicaid programs will submit proposals for competitive grants, with technical assistance provided. Selected projects will be monitored and evaluated.

Sample Detailed Timeline

0-6 months: HHS Secretary announces and launches the AIM Initiative, includes funding in the budget request.6-12 months: CMMI engages with state Medicaid agencies and selects proposals for pilot funding.Year 2-7: Launch and roll out selected AI projects with continued technical assistance.Year 8: Produce an evaluative report and recommend broader adoption.

Risks and Limitations

Participation: Success depends on state and private-sector participation. CMMI will engage with the National Association of Medicaid Directors and startups. Oversight: Guardrails are crucial to protect patients. State Medicaid agencies must submit evaluation plans, and technology partners must meet certain standards. Longevity: As a pilot program, it only facilitates short-term projects. HHS leadership must ensure program evaluation and long-term integration.Conclusion: The AIM Initiative is a significant step in bringing AI's promise to all Americans. It engages stakeholders and positions the US as a leader in healthcare AI. Addressing market failures in digital health can unlock efficiencies and bridge the health equity gap. This policy memo is part of Day One 2025, aiming to tackle challenges and create a better future.