About a month ago (mid-March), CMS introduced a pilot program called the Medicare Care Choices Model. Basically, this pilot program will allow Medicare beneficiaries to access, via certain participating hospice organizations, dual benefits; hospice and curative treatments, concurrently. Under the current Medicare Hospice Benefit, a patient with a terminal illness or condition, certified likely to die in 6 months or less by a physician, can enroll into the Hospice Benefit but in doing so, forgoes the traditional coverage for curative treatments under traditional Part A. Essentially, by electing the Medicare Hospice Benefit, the patient has decided not to pursue an aggressive path of cure or curative interventions or treatment (chemotherapy, radiation therapy, artificial hydration/nutrition, etc.) opting instead for palliative care, symptom management, and a progressive path toward natural death.
In the Medicare Care Choices Model, Hospices that apply and are selected to participate in the program will provide services available under the Medicare hospice benefit for routine home care and inpatient respite levels of care that are not separately billable under Medicare Parts A, B, and D. The services must be available 24 hours per day and across all calendar days per year. CMS will pay a $400 per beneficiary per month fee to the participating hospices for these services. Providers and suppliers furnishing curative services to beneficiaries participating in Medicare Care Choices Model will continue to bill Medicare for the reasonable and necessary services they furnish. Per CMS, the ideal hospice applicants for program participation can demonstrate a history of providing care/case coordination to patients, across a continuum of providers and suppliers.
Returning to the title of this post: Is this progressive on the part of CMS? The truth is best answered – “not really”. There are a number of current issues with regard to the Medicare Hospice benefit, care utilization, end-of-life care in general, and yes, the ACA at play. Under the ACA/Obamacare, the Secretary of HHS has a mandate to implement changes to the Medicare Hospice benefit no earlier than October 1, 2013. Abt and Associates (consultants) has been gathering and analyzing data on lengths of stay, place of care, length of stays in hospice by diagnosis, costs of care, etc. The Medicare Care Choices Model is in certain respects, a trial balloon element in the process of overhaul for the Medicare Hospice benefit.
Another operative element or issue and one that hospices are all too familiar with of late is the utilization pattern changes that are occurring across the spectrum of end-of-life care. Hospice referral patterns haven’t changed much but the nature of the referral has. Additionally, census trends for most hospices are flat and when viewed with/against lengths of stay, the trends are actually “down”. In short, an evolving dichotomy for hospice referrals is occurring. The referrals are modestly increasing in many urban/suburban regions but at the expense of the length of stay. The patient is finally referred at the end of his/her life, after all curative options are exhausted. Per CMS, 44 percent of Medicare patients use the hospice benefit at end-of-life but in a continuing pattern, at the end of life resulting in shorter and shorter stay increments.
Back to the question in the title of the post, this initiative is less about promoting or integrating hospice earlier, though the outcome of earlier intervention could occur. What CMS is tinkering with or intending to impact, is the continued growth of very expensive medical care in the last months of life. The two greatest drivers for Medicare spending in the U.S. are the cost of caring for “lifestyle” diseases (chronic diseases such as Type II diabetes) and care provided within the last six months of a person’s life. The latter is the target for this program. The premise is as such. If, by integrating hospice into the equation sooner, having removed the curative or interventional obstacle, patients will transition earlier to palliative care, foregoing certain last rounds of inpatient, interventionist care and thereby, save the government money. The patient and the curative care team (the physician, hospitals, etc.) will be less loathe to refer to hospice and address the prospect of treatment futility (even though that prospect is real) since, under this program, the patient may continue to pursue as much interventional and curative approaches as desired.
My quick analysis is that this program, while a novel approach, doesn’t really achieve any of the objectives intended (savings, better care, easier transitions, earlier transitions, more appropriate care, etc.). My reasons and conclusions are as follows;
- The issue of when a patient chooses to opt for end-of-life care versus curative care is more an American cultural/social issue than a public policy issue. As Americans, we are inculcated that death is bad, life is premiere. Our health insurance, especially now with ACA reforms, has virtually no limits on the treatment we can access (no lifetime minimums and no pre-existing condition limitations). Our media (television, print, other) is full of advertisements of procedures, drugs, providers that offer hope and cure. Watch a Cancer Treatment Center of America spot – a prime example. Physician specialists aren’t trained to forego what may clearly be futile care but instead, to press forward and to convey options and hope. In fact, the number of physician specialty groups that I have spoken with over the years validates this point emphatically: “Hospice is futility. We provide hope”. This element is the leading cause of late stage referrals when in validation, futility is truly evident as the patient is nearly dead or the final rounds of whatever treatment have shown no result.
- There is no financial incentive to change or alter the care provided. In the Choices model, the patient may access curative care and receive hospice services. The hospice receives $400 more per month (for care coordination) and all other provides bill Medicare for their interventions, services, etc. If CMS is relying on the care coordination skills of the hospice to facilitate better choices by the patient, his/’her family and/or the other providers, they are truly foolish. These groups have no financial incentive to partner on best choices and unless, CMS provides regulatory boundaries or payment incentives aligned to certain behavior, the savings will be minimal.
- There isn’t a real incentive for patients to enroll in this pilot project, other than they can get routine home care, respite, etc. benefits from the hospice. In reality, patients who are going to pursue curative options aren’t thinking hospice options. Likewise, the providers offering the curative interventions aren’t talking hospice options at this point. Our current healthcare system doesn’t function on this integrate plane. Thus, there truly is no motivation across the actors (hospice, curative providers, patients, families) to change current behavior. In fact, I see a risk for new avenues of improper utilization, qualification and abuse. Enrollment in hospice under this program is going to be challenging to qualify and quantify as in theory, where is the point of terminality (without intervention, death is likely in 6 months).
It will be interesting to watch how this program rolls-out and how CMS addresses or attempt to address the nuanced and overt regulatory issues that today, are separate and distinct by benefit programs. Likewise, it will be interesting to see how patient utilize, if they do to any extent, this hybrid model. The economist in me tells me that the concept and programmatic approach makes financial sense but operatively, this isn’t a slam-dunk in terms of ever working in the real world. There are simply too many behavioral impediments today for this to be a truly successful model.