CMS Advance Care Planning Measure: Home Health Reimbursement at Risk?

The United States healthcare system is once again grappling with the complexities of end-of-life care, as the Centers for Medicare & Medicaid Services (CMS) proposes a new quality measure tied to advance care planning. While proponents say the move could encourage crucial conversations about patient wishes, concerns are mounting that the proposed rule, designated MUC202-020, could inadvertently penalize home health agencies, leaving them without adequate reimbursement for these vital services. This debate highlights a persistent challenge: how to balance cost containment with ensuring patients receive care aligned with their values and preferences.

The proposed measure would require healthcare providers – including hospitals, skilled nursing facilities, ambulatory surgery centers and crucially, home health agencies – to document whether patients 18 and older have had documented end-of-life conversations. This documentation would then be linked to reimbursement through the Merit-Based Incentive Payment System (MIPS). The intention, according to CMS, is to promote greater adherence to patient-centered care and potentially reduce wasteful spending on unwanted medical interventions. However, the lack of a clear payment mechanism for home health agencies to conduct these conversations is raising significant alarm bells within the industry.

The Reimbursement Disparity

The National Alliance for Care at Home has voiced support for the *spirit* of the measure – the importance of advance care planning – but has sharply questioned its practical implementation. The Alliance points out a critical inconsistency: while physicians and qualified healthcare practitioners are already compensated for advance care planning discussions, home health agencies are not. This creates a situation where agencies are expected to perform the same task, contributing to the same quality metric, without receiving commensurate financial support. “Leaving them without appropriate compensation for this vital patient service in contrast to other settings where this MUC would also be applicable,” the Alliance stated. This disparity could discourage home health providers from prioritizing these conversations, ultimately undermining the measure’s goals.

The financial implications are substantial. According to estimates, approximately 36% of U.S. Adults have documented their end-of-life wishes. This lack of preparation often leads to more aggressive, and potentially unwanted, medical care. Bryan Sivak, founder and managing partner of the venture capital firm Evidenced, and a former chief technology officer for CMS, estimates that around $200 billion annually is spent on care that patients would not have chosen if they had clearly articulated their preferences. Addressing this issue through proactive advance care planning, he argues, is a “no-brainer” for healthcare cost savings.

The Role of Advance Care Planning and Hospice

Advance care planning encompasses a range of discussions and legal documents – including living wills and durable powers of attorney for healthcare – that allow individuals to express their wishes regarding medical treatment in the event they are unable to do so themselves. These conversations are particularly important for individuals facing serious illness, and are closely linked to increased utilization of hospice services. A 2025 study published in the journal JCO Oncology Practice demonstrated a clear association between advance care planning and increased hospice enrollment.

Interestingly, the proposed CMS measure specifically excludes the Hospice Quality Reporting Program. This omission is particularly noteworthy, given that advance care planning is considered a cornerstone of high-quality hospice care. This exclusion further exacerbates the concerns raised by home health agencies, as it creates a fragmented system where some providers are incentivized to engage in advance care planning while others are not.

Technological Solutions and Quality of Process

Companies like Koda Health are emerging to address the logistical and emotional challenges of advance care planning. Founded in 2020 by Tatiania Fofanova, Dr. Desh Mohan, and Katelin Cherry, Koda Health aims to streamline the process and ensure that patient preferences are accurately documented and communicated. Fofanova emphasizes the potential for significant savings, stating that intervening earlier in the course of illness, rather than solely at the end of life, can dramatically improve care alignment and reduce unnecessary costs. The company’s origins lie in the Texas Medical Center’s (TMCi) Biodesign program, where the founders collaborated on solutions to systemic healthcare problems.

However, Dr. Mohan, Koda Health’s Chief Medical Officer, cautions against a “check-box” approach to the CMS measure. He stresses that simply documenting the *occurrence* of an advance care planning conversation is insufficient. A truly effective process must delve deeper, documenting the patient’s values, quality of life preferences, identifying a surrogate decision-maker, and fostering a “continuum of understanding” regarding the individual’s goals. The specific requirements for documentation under the CMS measure remain undefined, raising concerns that providers may focus on compliance rather than meaningful engagement with patients.

Ensuring High-Quality Advance Care Planning

A high-quality advance care planning process, according to experts, should include several key elements. These include a thorough discussion of the patient’s values and beliefs, a clear understanding of their medical options, and the designation of a trusted individual to make decisions on their behalf if they become incapacitated. It’s not simply about filling out forms; it’s about fostering a shared understanding between the patient, their family, and their healthcare team. This requires dedicated time, skilled communication, and a commitment to patient-centered care.

The National Partnership for Healthcare and Hospice Innovation has publicly endorsed the proposed CMS measure, signaling broad support for the underlying principle of promoting advance care planning. However, the concerns raised by the National Alliance for Care at Home regarding reimbursement remain a significant obstacle to successful implementation.

What Happens Next?

The CMS proposal is currently open for public comment. The deadline for submitting comments is May 6, 2026. Following the comment period, CMS will review the feedback and may revise the proposed rule before issuing a final regulation. The final rule is expected to be published in late 2026, with implementation potentially beginning in 2027. Stakeholders are actively engaging with CMS to advocate for a fair and sustainable reimbursement model for home health agencies, ensuring that they can continue to provide this essential service without facing financial hardship.

The debate surrounding this CMS proposal underscores the ongoing tension between cost control and quality of care in the American healthcare system. While the goal of promoting advance care planning is laudable, the success of this initiative hinges on addressing the financial concerns of home health providers and ensuring that they are adequately compensated for their contributions. Without a viable reimbursement mechanism, the measure risks becoming another well-intentioned policy that falls short of its potential.

What are your thoughts on the CMS proposal? Share your comments below, and let’s continue the conversation about how to improve end-of-life care for all.