# To bill or not to bill – a cross-sectional study comparing funded and unfunded advance care planning services in German nursing homes

## TL;DR

This study compares German nursing homes that can bill for advance care planning with those that cannot, finding higher use of advance directives in the former.

## Contribution

The study provides empirical evidence on how billing approval for ACP affects its implementation and end-of-life care structures in German nursing homes.

## Key findings

- Nursing homes with ACP billing approval had significantly higher rates of advance directives and health care proxies.
- Emergency plans were not significantly different between the two groups.
- ACP was available in both groups, but quality assurance is needed for documentation and utility of precautionary documents.

## Abstract

In 2018, § 132g of the German Social Code, Book V (SGB V), came into force, allowing long-term care facilities in Germany to bill statutory health insurance for advance care planning (ACP). The present study examined differences in end-of-life care structures between nursing homes that had obtained approval for billing ACP and those that had not (and do not intend to obtain this approval), as well as the extent to which ACP is available to residents beyond the scope of these billing options.

A nationwide cross-sectional survey was conducted in 2023 among a random sample of 1,369 German nursing homes. The questionnaire, primarily targeting nursing home management staff, aimed to evaluate hospice and palliative care structures and ACP implementation. This manuscript compares nursing homes that had obtained approval for ACP billing with those that had not received approval and had no intention of applying for it; therefore, a subset of the returned questionnaires was used for analysis.

A total of 330 questionnaires were received (response rate 24%; mostly completed by nursing home management staff), enabling the comparison of 100 nursing homes with ACP billing approval and 68 without. ACP was more prevalent in nursing homes with billing approval (96.0% vs. 36.4%; p < 0.001). While nursing homes with approval reported higher proportions of residents with written health care proxies (66.7% vs. 58.7%; p = 0.049) and advance directives (68.5% vs. 55.6%; p < 0.001), no significant difference was found in the presence of emergency plans (36.0% vs. 37.6%; p = 0.782). Furthermore, a substantial rate of at least one of these three precautionary documents was not considered useful in cases of hospitalization or cardiac arrest. Both nursing home groups reported strong collaboration with external palliative care providers, particularly general practitioners.

ACP appears accessible in nursing homes that have obtained approval for billing ACP, as well as in those that have not. Nursing homes with approval have a higher proportion of residents with advance directives. However, the limited presence of emergency plans and concerns about the utility of the three precautionary documents highlight the need for quality assurance in ACP consultation and documentation.

The online version contains supplementary material available at 10.1186/s12913-025-13848-6.