Healthcare executives continue to grapple with a longstanding problem: despite pouring billions of dollars into end-of-life care, patient satisfaction remains mediocre at best. The American healthcare system defaults to aggressive interventions—ICU admissions, mechanical ventilation, emergency surgeries—that often do little to improve a patient’s quality of life. The irony is that most patients, when asked, say they would prefer a different approach. They want comfort-focused care, fewer hospital stays, and more time at home with family. Instead, they receive a cascade of high-cost, low-value treatments that are neither what they want nor what they need.
The numbers paint a sobering picture. End-of-life care accounts for a staggering 25 percent of all Centers for Medicare and Medicaid Services (CMS) spending. The cost per day in the final three days of a hospitalization is nearly ten times what it is earlier in the stay. Meanwhile, hospice care—a far more cost-effective and patient-preferred option—remains underutilized. For a healthcare system that prides itself on efficiency and evidence-based medicine, this disconnect is more than just a clinical issue; it is an operational and economic failure.
Advance care planning, or ACP, offers a way out of this paradox. When patients have meaningful conversations about their goals for care, the results are striking: fewer unnecessary hospitalizations, lower emergency department utilization, and a much greater likelihood that patients receive care aligned with their wishes. The problem is that, despite its benefits, ACP remains an afterthought in many healthcare organizations. The challenge now is not proving that ACP works—it is ensuring that healthcare leaders integrate it meaningfully into their systems.
The data are clear: ACP reduces healthcare utilization
A recent multicenter cohort study provides compelling evidence for the value of ACP in patients with chronic neurodegenerative diseases, including Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, and ALS. The study, which analyzed data from over 4.8 million patients, found that those with documented ACP discussions had 20 to 30 percent fewer emergency department visits over a two-year period. Alzheimer’s patients saw a 12 percent reduction in hospitalizations, a finding that underscores the power of ACP to reshape healthcare utilization patterns.
Perhaps most striking was the shift in utilization trends before and after ACP discussions took place. Patients who had been on an upward trajectory of increasing hospital and emergency department visits suddenly saw those trends reverse after ACP documentation. These conversations, when they happen, change not just the care a patient receives but the very trajectory of their healthcare journey. For hospital executives focused on financial sustainability and patient-centered care, this should be a wake-up call.
Yet, despite these benefits, ACP remains vastly underutilized. Fewer than four percent of patients in the study had an ACP discussion documented through billing codes. The reasons for this are complex but not insurmountable.
Why aren’t more clinicians using ACP?
One major barrier is the misalignment between ACP’s value and how healthcare organizations incentivize physician behavior. While Medicare does reimburse for ACP discussions, the financial incentive alone has not driven widespread adoption. Physicians are pressed for time, often struggling to fit ACP into already overburdened workflows. The discussion itself is nuanced, requiring skill and time, yet clinicians are not given clear productivity offsets or institutional encouragement to prioritize it.
Beyond logistical constraints, ethical concerns also play a role. Many physicians feel uncomfortable billing for conversations about death and dying, particularly when there is uncertainty about prognosis. Some providers worry about burdening patients with unexpected charges, even though Medicare waives the copay if ACP occurs during an Annual Wellness Visit. As a result, discussions that should be routine become sporadic, delayed, or nonexistent.
Another critical challenge is the fragmented nature of ACP within the care continuum. These conversations often fall to primary care providers, while specialists managing progressive diseases may not consider ACP their responsibility. This diffusion of accountability means that even in high-risk populations, many patients never engage in ACP discussions at all. Without a clear, systematic approach to ACP integration, it will continue to be deprioritized, regardless of the evidence supporting its benefits.
How health systems can scale ACP for maximum impact
For ACP to become a meaningful driver of patient-centered care and financial sustainability, healthcare leaders must take deliberate steps to embed it into their organizations. The first step is to shift the perception of ACP from an optional conversation to a standard of care, particularly for patients with chronic and progressive diseases. ACP should be treated as an ongoing process, not a one-time event, and should be incorporated into routine clinical encounters rather than reserved for crisis moments.
Operationally, this requires structured triggers within the electronic health record (EHR) to identify patients who would benefit from ACP. Predictive analytics can help flag high-risk individuals, ensuring that conversations happen earlier in the disease course rather than in the final weeks of life. Clinicians must be trained to have efficient, meaningful ACP discussions, with tools such as structured conversation guides and decision aids to support them.
Financial incentives must also be realigned. While ACP billing codes exist, they are not enough on their own to drive adoption. Tying ACP discussions to broader value-based care metrics—such as reductions in ICU days or hospital readmissions—would provide a more compelling reason for organizations to prioritize them. Healthcare systems should also consider offering relative value unit (RVU) credit for ACP, ensuring that physicians are recognized for the time and effort these discussions require.
Beyond provider engagement, patient and family education is critical. Many individuals do not fully understand the purpose of ACP, or they assume that having a living will is sufficient. Health systems should implement public-facing education initiatives to normalize ACP discussions, making it clear that these conversations are about empowering patients, not limiting their options.
To measure success, executives must track key performance indicators (KPIs) related to ACP adoption. Data on hospitalizations, emergency department visits, hospice utilization, and patient satisfaction should be routinely analyzed to demonstrate ACP’s impact. When executives have access to clear, data-driven validation of ACP’s effectiveness, it becomes far easier to justify continued investment in these programs.
Conclusion: A strategic imperative for healthcare leaders
The evidence is undeniable: ACP reduces unnecessary healthcare utilization, lowers costs, and improves patient satisfaction. The question is not whether ACP works, but why healthcare leaders have not yet made it a cornerstone of their organizations. The current system rewards volume over value, and ACP remains an afterthought in many health systems precisely because it does not fit neatly into existing financial and operational models. That must change.
For healthcare executives, ACP presents a rare opportunity to implement a cost-saving, patient-centered intervention with immediate return on investment. The challenge is not proving its value but rather ensuring that hospitals and health systems have the operational infrastructure to support it at scale. This requires a shift in mindset. ACP is not just a checkbox or a compliance measure—it is a critical pillar of value-based care that has the potential to transform how we deliver end-of-life care in America.
If the healthcare industry is serious about reducing costs while improving patient outcomes, one solution is clear. Advance care planning must move from the margins to the mainstream, embedded into the very fabric of how we deliver care. The time to act is now.