On July 31, 2026, the Centers for Medicare & Medicaid Services finalized a significant change.
CMS adopted the Advance Care Planning electronic clinical quality measure (eCQM) for the Hospital Inpatient Quality Reporting Program beginning with the FY 2030 payment determination. CMS also adopted the ACP eCQM for the Medicare Promoting Interoperability Program in alignment with Hospital IQR.
That is a lot to take in at once, so read it again if you need to. This is important.
Essentially, CMS is signaling that ACP belongs within the healthcare quality infrastructure.
Hospital IQR is a Medicare pay-for-reporting quality program. CMS states that hospitals failing to submit required quality data or satisfy program requirements can receive a reduction in their annual Medicare payment update.
What Does This Mean For You As The Patient
Advance care planning documentation has therefore crossed an important threshold because it is becoming part of the quality infrastructure by which hospitals demonstrate performance to CMS.
That sounds like a good thing, right? Well, when end of life care plans and advance care planning documentation are tied to CMS, it creates an environment where hospitals will want to quickly create more advance care plans for their patients, but without having the skills and expertise to do it correctly.
And when that happens statistics can be manipulated. For example:
- A hospital can increase the number of advance directives in its EHR
- A health plan can increase the number of members approached about advance care planning
- A vendor can increase the number of forms completed
None of those statistics necessarily tells us whether the patient understands the risks and benefits of the choices being documented or whether clinicians will correctly interpret those choices during an emergency.
That distinction may become one of the most important patient-safety issues created by this new quality measure.
The Wrong Response to the CMS Measure
The danger becomes that once healthcare organizations are measured on something, enormous resources are directed toward improving that number.
That can be very good when it is done safely and correctly.
But imagine if the response to the new ACP measure becomes:
Find more patients. Complete more documents. Put more ACP documentation into the EHR.
Our worry is that hospitals may turn this into just end of life planning and look to outside vendors to try to get as much end of life care plan documentation as possible. To make that happen, many health plans and insurance companies may try to expand home-based ACP programs. Third-party organizations may be asked to reach thousands of patients quickly to get them to sign rushed advance directive planning documentation or immediately actionable medical orders that may reflect an end of life plan but not the current plan for your active and aggressive medical care needs.
While rushing a bunch of end of life care plans into the EHR will help improve their metric, that doesn't mean it is benefiting the patient. The Journal of Patient Safety has published that advance directives and Portable Orders for Life Sustaining Treatment are causing widespread medical errors related to both over and under treatment of patients. Therefore, both hospitals and insurance companies need to ask themselves right now if this approach will actually:
- Improve the patient's understanding of what they signed in their advance directive
- Create more discussions about end of life plans, or cause more confusion
- Improve patient safety
- Help patients understand the difference between an advance directive, DNR, and end of life care decisions
- Review of existing advance directives
- Make sure physicians and medical teams can retrieve and understand the information when it is needed
We want advance care planning to be measured for informed decision making and not just as a documentation race.
These documents can influence whether someone receives CPR, whether they are intubated, or whether they are transferred to a hospital, and an advance directive helps determine whether someone's life will be saved during a medical emergency.
We have a responsibility as physicians and medical providers to get this right, and sending third-party contractors to people's houses to get them to quickly sign off on their end of life care plan is not the way to correctly do this. Having an advance directive created in a hospital during a medical crisis is also not the best time to do this.
ACP should never be a transactional encounter. It is absolutely a clinical process and requires the clinical eye of a physician who actually knows the patient and their history.
What This Means for Hospital Systems
Hospital leaders now have a choice to make, and the window to make it thoughtfully is closing.
They can build systems designed to maximize documentation. Or they can build systems designed to maximize informed patient decision-making, clinical clarity, retrievability, and goal-concordant care. Only the second one improves patient safety.
However, the pressure to choose the first option will be real.
MIDEO Suggests Creating Best Practices with Advance Directives
MIDEO was created to make sure that your wishes are unmistakable during the event of a medical emergency.
In fact, Dr. Mirarchi's TRIAD patient-safety research began because of an incident where he nearly harmed a patient after misinterpreting an advance directive.
The research that followed demonstrated something medicine should take note of today, especially in light of the new CMS measures. The biggest finding was that legal validity does not guarantee clinical clarity.
If you are a patient or family member
Your advance directive should be created with thought, with people who know your medical history. MIDEO helps you state your wishes in your own words, on video, paired with your legal documents and retrievable at the bedside in seconds.
You may only get one chance, so be sure your advance care plan is created safely.
Create your MIDEO advance directive
If you are a hospital or health system
Meeting the CMS measure and doing advance care planning well will require a truly thoughtful approach. You need to meet your requirements, but your patients' safety should always come first.
MIDEO is a way to help hospitals and health insurers document ACP. We are setting standards for ACP best practices to ensure informed patient decision making.
MIDEO was created by an emergency room physician specifically to close the gap between what patients document and what clinicians understand. We work with health systems on ACP programs that are clinically accurate and easily retrievable during a medical emergency.
If you want to discuss how MIDEO can help your hospital system or healthcare facility safely document ACP to meet the CMS requirement, we want to help.
