title: Public Opinion Regarding Financial Incentives to Engage in Advance Care Planning and Complete Advance Directives.
abstract: BACKGROUND
  The Centers for Medicare & Medicaid Services (CMS) recently instituted physician reimbursements for advance care planning (ACP) discussions with patients.
  
  
  OBJECTIVE
  To measure public support for similar programs.
  
  
  METHODS
  Cross-sectional online and in-person surveys.
  
  
  METHODS
  English-speaking adults recruited at public parks in Philadelphia, Pennsylvania, from July to August 2013 and online through survey sampling international Web-based recruitment platform in July 2015. Participants indicated support for 6 programs designed to increase advance directive (AD) completion or ACP discussion using 5-point Likert scales. Participants also indicated how much money (US$0-US$1000) was appropriate to incentivize such behaviors, compared to smoking cessation or colonoscopy screening.
  
  
  RESULTS
  We recruited 883 participants: 503 online and 380 in-person. The status quo of no systematic approach to motivate AD completion was supported by 67.0% of participants (63.9%-70.1%). The most popular programs were paying patients to complete ADs (58.0%; 54.5%-61.2%) and requiring patients to complete ADs or declination forms for health insurance (54.1%; 50.8%-57.4%). Participants more commonly supported paying patients to complete ADs than paying physicians whose patients complete ADs (22.6%; 19.8%-25.4%) or paying physicians who document ACP discussions (19.1%; 16.5%-21.7%; both P < .001). Participants supported smaller payments for AD completion and ACP than for obtaining screening colonoscopies or stopping smoking.
  
  
  CONCLUSIONS
  Americans view payments for AD completion or ACP more skeptically than for other health behaviors and prefer that such payments go to patients rather than physicians. The current CMS policy of reimbursing physicians for ACP conversations with patients was the least preferred of the programs evaluated.
authors.affiliation: 1 Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.|2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Catherine L
authors.initials: CL
authors.lastname: Auriemma
authors.affiliation: 2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.|3 University of Pennsylvania, Philadelphia, PA, USA.|4 Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Lucy
authors.initials: L
authors.lastname: Chen
authors.affiliation: 2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.|4 Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Olorunnisola
authors.affiliation: 2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.|5 Wayne State School of Medicine, Detroit, MI, USA.
authors.forename: Aaron
authors.initials: A
authors.lastname: Delman
authors.affiliation: 2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.|4 Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.|6 Harvard University, Cambridge, MA, USA.
authors.forename: Christina A
authors.initials: CA
authors.lastname: Nguyen
authors.affiliation: 2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.|4 Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Cooney
authors.affiliation: 2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.|7 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Nicole B
authors.initials: NB
authors.lastname: Gabler
authors.affiliation: 2 Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.|4 Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.|7 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.|8 Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA.|9 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Halpern
mesh_terms: D000293:Adolescent; D000328:Adult; D032722:Advance Care Planning; D016223:Advance Directives; D000368:Aged; D003258:Consumer Behavior; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009042:Motivation; D010361:Patients; D010820:Physicians / Q000191:economics; D011639:Public Opinion; D012959:Socioeconomic Factors; D055815:Young Adult
keywords: advance care planning; advance directive; end of life; incentives; public opinion; survey