Hospice HELP Act of 2013

Some quick thoughts on the “Hospice Evaluation and Legitimate Payment Act of 2013″ the so-called HELP hospice Act (h/t for the text to @HospiceAction).

• It is co-sponsored by a Democratic Senator (Ron Wyden of Oregon), and a Republican (Pat Roberts of Kansas). Until the unhinged and fact free death panel rants of August 2009 and continuing, the hospice movement enjoyed bipartisan support, I think because everyone eventually dies and it is in everyone’s self interest to improve the options of those who are acutely facing death. That bipartisanship has been on hiatus since the passage of the ACA. For example, the word palliative care does not appear in the ACO regulations, and the word hospice appears only once. However, these are both crucial in any attempt to deliver care to a defined population of elders with the goal of increasing quality of life/value of care while addressing costs. If the HELP hospice Act goes forward, it will show we have been able to get back to some policy in this general area.
• The bill proposes a modification of the face-to-face encounter re-certification provisions in hospice when a patient uses hospice beyond the first 60 day eligibility period. The big picture is worries about increasingly long stays among long stayers as outlined by MEDPAC. The goal is to right-size the regulation and not make it too burdensome, while making sure use is appropriate.
• Proposes a hospice payment demonstration to replace the 30 year old per diem payment approach.  This would delay the Secretary of HHS’s ability to bring about a new hospice payment system (which cannot be done before October 1, 2013 under the auspices of the ACA), but with the HELP hospice bill it could not be done until October 1, 2017, after the proposed demonstration. Most of the bill details how this demonstration should be done (include at least 15 representative hospice providers, have an evaluation and report, the 2 year demonstration must be budget neutral). Note, this is not the same 15 hospice demonstration that was enabled by the ACA for testing concurrent care, but that has not been funded. However, I read the language of the HELP hospice Act to be broad enough to encompass this concurrent idea.
• Sets up a regular survey requirement for hospice providers by a local of State accreditation agency once every 36 months.

Hospice policy questions used to be dealt with in a bipartisan fashion. It will be interesting to see if we have gotten back to the point at which we can have any health policy legislation move ahead in its own right, and not simply become the next volley in the ongoing meta health policy wars. The hospice tag of this blog will get you much more info on this area if you want it.

New paper confirms hospice reduces Medicare costs

A new paper in Health Affairs by Amy Kelley and colleagues shows that hospice reduces Medicare costs as compared to what they would have been had hospice not been chosen by the patient over a variety of common lengths of use in the Medicare program.

The paper is in many ways a replication of the 2007 study (funded by the HCFO initiative of RWJ) that I did with colleagues at Duke that found mean savings after the point of hospice election of just over $2,300, and that the savings (hospice costs after election as compared to normal care) were maximized with a length of hospice use of between several weeks and a few months.

Kelley et al.’s paper goes beyond ours in that it controlled for functional status of persons in hospice measured at a finer level than could the work that we had done. This lead to reasonable wonders about the impact of potentially important omitted variables in our work. The work of Kelley and colleagues has confirmed and extended our general finding that hospice saves Medicare money after accounting for the fact that patients choose hospice–and therefore are systematically different from those who do not. They identify larger savings very near death than did we. It should be noted that in addition to controlling for functional status variables that were omitted in our work, the current paper also is done on more recent data years (2002-08; our paper went back into the 1990s-2005). For example, they find hospice reduced Medicare costs by $2,650 for hospice stays of 1-7 days; $5,040 for those lasting 8-14; and $6,430 for stays of 15-30 days. Given that the median length of hospice use is around 18 days in the Medicare program, over the most typical range of use, hospice should be encouraged, and policies to increase use identified. The ‘short stay’ problems should not be forgotten while trying to address problems related to very long stays.

I know of nothing else that improves quality of life of patients and routinely reduces costs that is paid for by Medicare.

A word on data. The Health and Retirement Survey (HRS) is a massive, long term data effort funded by NIH for the past 20 years. HRS enrolled panels of patients and followed them over time. Amy’s paper took advantage of the joining of self-reported data on function collected in such surveys, to Medicare claims data that documents use and cost paid by the Medicare program. Such collection and linkage and time consuming, expensive and hard. Without the foresight of NIH to invest in data, this paper would not exist. A hole remains in the hospice literature because Medicare Advantage plans do not have to make claims data available as a matter of course. This makes no sense for a nation trying to address cost, coverage and quality issues in health care. update: when Med Advantage patient elects hospice they revert to Part A. The difficulty of claims from Medicare Advantage is a general problem.

If you enter the search term hospice into the blog sidebar, you get many posts on hospice policy if you want to read more.

Note: paper is gated; working on a clean link.

Amy S. Kelley, Partha Dah, Qingling Du, Melissa D. Aldridge Carlson, R. Sean Morrisson. Hospice Enrollment Saves Money for Medicare and Improves Quality Across A Number of Different Lengths-of-Stay. Health Afffairs 2013;552-61.

Hospice and functional decline

An interesting new paper in the Journal of the American Geriatrics Society (JAGS) on different patterns of functional decline (ability to walk, eat, cognition) among persons who were in hospice care and ultimately died. The most important point of the paper is that there is great heterogeneity in ability to function, even on the last day of life.

In an inverse probability–weighted sample of individuals who had a PPS score recorded in the last day of life (n = 1,959, 22.6%), 35.9% had a PPS score of at least 40, indicating some oral intake, variable mental status, limited self-care, and an ability to get out of bed for at least part of the day. [my note: PPS in this context is a standard functional status measure often used in hospice and palliative care settings; 10 is quite poor, 90 is very good]

Two points on hospice policy here, both related to MEDPACs great interest in (shortening) long stay hospice users. First, over one-third of patients in this sample had reasonable functioning on the day they died. This shows the difficulty of predicting death with any precision, even among the subset of patients enrolled in hospice (all patients in this study died, so this is not an issue of discharging alive from hospice). Second, table 2 from this study demonstrates the current reality of hospice as not simply being used to treat Cancer; a broader set of conditions including dementia and debility(or frailty) are also included.  Such conditions tend to have a less clear disease course than does Cancer. Both the difficulty of predicting death, and the spread of hospice into non Cancer diagnoses (which has been a stated goal of Medicare hospice policy), have likely contributed to the  increase in relatively long hospice stays that have drawn so much policy attention. More work to demonstrate the link between functional status and length of hospice use/patterns is likely to be an important part of any Medicare hospice payment reform.

Pamela Harris, Esther Wong, Sue Farrington et al. Patterns of Functional Decline in Hospice: What Can Individuals and Their Families Expect. Journal of the American Geriatrics Society 2013 online first.

Bill Keller’s piece of end of life care

Bill Keller has an insightful piece on end of life care in England v. the USA, using the example of the recent death of his father in law. First, let me say that it is brave for a family to share such a personal story, and I want express condolences to the family.

A few policy thoughts on Keller’s piece:

• I agree with his notion that focusing on end of life care with the expressed purpose of saving money is likely to prove not only politically difficult, but it is hard for such efforts to work. That is because the “last year of life” is an inherently retrospective concept, and you don’t know when the last year started, until it ends. This makes it very hard to know when to shift into “cost saving” mode.
• One interesting note is that the proportion of total spending using the “last year of life” metric in the NHS is quite similar to that in the U.S. The tremendous difference is in the level of spending (on the order of $2 for $1 per capita) between the two nations.
• The citation Keller uses from Zeke Emanuel on limited cost savings of hospice is from 1994 and there is more recent work that does demonstrate that hospice reduces Medicare expenditures as compared to similar non-hospice users that has been published in the past several years (sorting out selection bias is a tremendous methodological challenge in this literature, meaning those choosing hospice differ from those who don’t in ways the impact health spending). One of the papers that sorted this out is my paper with colleagues from Duke. There are others.* I reviewed a new paper two weeks ago for a top journal that actually confirms and extends the findings from my paper (while including a richer set of matching variables). So, hospice remains just about the only thing of which I know that holds out the hope of reducing costs while improving quality of life (typically we are left to assess whether something with a marginal benefit at greatly increased cost “is worth it.”
• A reality is that the hospice benefit was “sold” in 1982 as a means of cost savings when it was added to the Medicare program. A recent paper of mine on some of this history.
• Medicare hospice policy greatly needs to be updated. The insanity of “death panels” and our inability to talk reasonably about something that will happen to each of us (death) greatly hinders good policy. My book frames this inability to face limits as a key source of inability to reasonably address health care costs.
• The antidote to what I have termed insanity, is to seek to ask three basic questions about all care, regardless of our belief about someone’s prognosis: does it improve quality of life? does it extend life? how much does it cost? These questions need to become part of our broad cultural dialogue about health care, as well as explicit parts of evidence based policy making.

For example, see:*Pyenson B, Connor S, Fitch K, Kinzbrunner B. Medicare cost in a matched hospice and non-hospice cohorts. Journal of Pain and Symptom Management 2004;28(3):200-12.

Shugarman L, Campbell D, Bird C, Gabel J, Louis T, Lynn J. Differences in Medicare expenditures during the last 3 years of life. Journal of General Internal Medicine 2004;19:127-35.

Medicare as insurance innovator: the case of hospice

I have a new paper* that is available online now at the American Journal of Hospice and Palliative Medicine.

The stylized fact is that Medicare has produced many insurance payment innovations (DRGs, prospective payment of hospitals, RBRVS), while private insurance has tended to innovate on the benefit side of the equation. The creation by Medicare of the hospice benefit in 1983 stands as a notable exception. The paper lays out the linkage between Medicare and private insurance coverage of hospice.

Interestingly, hospice is the only part of the Medicare benefit package that is carved out of the Medicare Advantage program. I am unsure of why this is the case. I believe it is likely related to the fact that hospice was created as a demonstration in Medicare as part of TEFRA 1982, as was what I think was the first private insurance option in Medicare. After both parts were later mainstreamed into Medicare, I think they were just never joined. However, it is also possible that it is related to the politics of hospice and end of life care generally. Those politics have only gotten worse (more hysteria, less reasoned discussion) in the last few years. I will be writing more about this and you have thoughts about why someone who elects hospice while in a Medicare Advantage plan reverts to FFS Medicare for hospice, let me know.

This is particularly important because of the strong sense from most hospice and palliative medicine experts that the Medicare hospice benefit needs to be updated, but that it is viewed as politically very hard to address policy focused on end of life. It is an important issue since ~8 in 10 deaths that occur in the U.S. each year occur in persons who are insured by Medicare.

Can hospice function under Medicare premium support?

Obviously we health policy types have been wonking it out about premium support in Medicare given the selection of Rep. Ryan as Gov. Romney’s running mate. Austin asked via twitter:

The short version is that hospice should be able to work under a private insurance option in Medicare that preserves the option of Seniors remaining in traditional Medicare, though there is a policy oddity regarding hospice and the current Medicare Advantage (MA) program that would have to be changed. Further, there are also some less obvious ways in which our lack of a straightforward long term care financing system will complicate hospice policy for the elderly going forward, especially if you coupled premium support with a block granting of Medicaid that was designed to reduce federal expenditures. This post is an overview, and I will revisit some of these topics in more detail.

• Current policy with MA. If a beneficiary covered by a Medicare Advantage plan elects hospice, then ALL payment for all of their health care reverts back to traditional Medicare after the election of hospice. This includes Part A payments of hospice services (see p.8-9), as well care covered by traditional Medicare’s benefit package (Parts A & B) that is unrelated to the terminal illness (ex. a hip fracture from a fall while in hospice [MA plans would still provide any extra benefits, such as dental care to their beneficiaries who had elected hospice]). Hospice has been “carved out” in this way since it was introduced to Medicare in 1982. It is not entirely clear to me why this is the case, and I have speculated a bit in the past and will write a longer follow up on the politics of hospice policy later.
• What would have to change under competitive bidding? Private plans would have to pay for hospice and other care if it was chosen by beneficiaries for traditional Medicare and private options to compete on an even footing.
• How common is it for MA patients to elect hospice as compared to traditional Medicare? MA patients are more likely to choose hospice than are beneficiaries in traditional Medicare, though the gap has been shrinking (47.8% of MA decedents v. 43% FFS in 2010; 30.9% MA v. 20.5% FFS in 2000 p. 288; longstanding p.141-143). MA plans have a financial incentive to encourage hospice selection because it pushes end-of-life costs to traditional Medicare, though a study testing whether making hospice a part of the capitation payment for MA* concluded that it would only save traditional Medicare a modest amount of money. However, this study focused on enrollment in hospice during the last month of life, which covers around two-thirds of users, using data from the 1990s. Since then, the expansion of hospice in Medicare has grown steadily, primarily through increased use of hospice by older beneficiaries, and via an increase in the use of hospice by persons with non-Cancer terminal diagnoses (like CHF and dementia). This means the tails of one side of the distribution (long users) have gotten a lot longer (90th percentile 150 days in 2000, 250 days in 2010 while the 25th percentile stay has been 5-6 days for 20 years. There is a literature on the correlates of hospice choice that partially line up with the correlates of MA advantage selection that I will post on later (urban, white, higher education and higher income are all more likely to choose MA, and hospice, even within traditional Medicare).
• It is not only about the costs. Hospice has been shown to increase quality of life prior to death, so while the above focuses on the shifting of costs from private insurance companies to traditional Medicare, another perspective is that MA decedents are more likely to reap the benefits of hospice prior to death and there is too much focus on cost in hospice policy in any event. In fact, from a quality standpoint, encouraging longer stays for most users would likely be associated with higher quality and lower costs to traditional Medicare. Cost and quality must be considered together.
• Can hospice exist in private insurance? Yes, it does now; private insurance policies for persons under the age of 65 routinely cover hospice. Indeed, Aetna** has innovated the hospice benefit structure in the under-65 population toward a “concurrent” benefit in which hospice care can be received without unelecting “curative” care, providing more flexibility than does the current policy for hospice in traditional Medicare. It is worth noting that a little over 8 in 10 persons who die in the U.S. are Medicare beneficiaries, so the under age 65 hospice experience in private insurance has been generated based on more “unusual” (probabilistically speaking) events, and is more cancer-focused than are overall Medicare hospice deaths.
• Long Term Care is muddied up with hospice policy. I believe that a lot of the angst over long hospice lengths of stay are driven by fears at CMS that hospice is in danger of turning into a back door long term care benefit. Most work on long lengths of hospice stay focus on Non Profit v. For Profit ownership of the hospice. I cannot find an analysis of whether long stay users are more likely to come from MA or traditional Medicare into hospice. Further, dual eligible Medicare beneficiaries are less likely to choose hospice than are non-duals (39.2% of decedents v. 45.5%, p. 288), as are Medicare beneficiaries in SNFs. This is due to perverse interactions between Medicaid and Medicare that mean in some states a dual eligible choosing hospice would become responsible for per diem room and board costs if they do so, almost certainly reducing quality and increasing aggregate cost (but shifting costs between Medicare and Medicaid). This is one thing that has lead me to call for federalizing the dual eligible Medicaid costs. Gov. Romney and Rep. Ryan favor block granting Medicaid, and this would likely exacerbate these perverse incentives since increased flexibility to states would come with less money under likely block granting scenarios. At a minimum, the lack of a coherent LTC financing system makes hospice policy more difficult, especially given that around 9 in 10 hospice decedents receive such care in their home.

In short, hospice is the part of private insurance options in Medicare that will have to change the most if we move toward a premium support option based on competitive bidding. It should be doable, but, as always, the details are crucial.

update: a few tweaks for clarity and I initially forgot to list the two papers below.

*G. Riley, C. Herbolsdheimer. Including hospice in Medicare capitation payments: would is save money? Health Care Financing Review 2001;23(1): 137-147.

**Krakauer R, Spettell CL, Reisman L, Wade MJ. Opportunities to Improve the Quality of Care for Advanced Illness. Health Affairs 2009; 28:1357-59.

Discharge from hospice alive

Paula Span recently wrote about hospice as a shield against unwanted medical treatments that provided the space for an elderly Medicare beneficiary to get better. The irony is that the family she writes about had to choose the option associated with imminent death to be able to take their mother home and allow her to receive competent care that her adult children could trust; eventually, she was discharged alive from hospice. Work that I did with colleagues at Duke shows that around 15% of Medicare beneficiaries who begin hospice are discharged alive (85% of Medicare beneficiaries choosing hospice used such care continuously until their death, an average of 50 days later; median 15 days, Group 1 below).

Taking responsibility for death

Susan Jacoby has a nice piece in the NY Times recounting the story of how her mother faced her death–clear eyed and asking questions about what medical treatments could realistically provide for her, and then making decisions based on her preferences. This is a good story to emulate.

It will be hard to revolutionize our cost problem by focusing on the issue of spending near death alone, in part because it is not clear when the last year of life started until it ends, and in part because our culture goes vaguely insane with charges of death panels, etc. Instead, we need need to more comprehensively ask three questions: will this improve my quality of life? will it extend my life? how much does it cost?

The asking of these questions will likely be the most consequential in terms of cost near the end of life, but we need to learn to ask them all the time as a matter of course if we are to become comfortable with them as a loved one is dying.

Echoes of published research

Brian McMichael has a post on the “echoes” of a RCT published in the NEJM in August 2010 showing that early palliative care improved quality of life, increased survival and reduced costs. By echoes, he means that this study served as the catalyst (along with others) that spurred a change in a policy statement by a specialty group, when the American Society of Clinical Oncology released a Provisional Clinical Opinion (background, the original study) that states that palliative care should be a fundamental part of cancer care for someone diagnosed with metastatic or advanced cancer.

Provisional Clinical Opinion Based on strong evidence from a phase III RCT, patients with metastatic non–small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care–when combined with standard cancer care or as the main focus of care–leads to better patient and caregiver outcomes. These include improvement in symptoms, QOL, and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care. While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving, no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. Therefore, it is the Panel’s expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden….

The provisional clinical opinion goes on to state:

…Strategies to optimize concurrent palliative care and standard oncology care, with evaluation of its impact on important patient and caregiver outcomes (eg, QOL, survival, health care services utilization, and costs) and on society, should be an area of intense research.

Figuring out to optimize the provision of palliative care alongside standard oncology care is the key. How to bring this evidence from a RCT to bear in a manner that helps patients, and hopefully improves the productive efficiency of care delivered to persons who are suffering from advanced cancer is important. Bit by bit, this is how we move ahead.

DT

Hastings Center Awards

The 2012 Cuniff-Dixon Awards bestowed by the Hastings Center to physicians for excellence in providing care at the end of life, and my friend and colleague Janet Bull, Chief Medical Officer of Four Seasons Hospice and Palliative Care in Fletcher, N.C. has been awarded the senior physician prize for 2012. Janet is a passionate physician and patient advocate who has also invested a great deal of time and energy to building the research infrastructure in palliative care and hospice.

Janet was trained as an OB/GYN, and her perspective of End Of Life (EOL) care as an inevitable part of life is an interesting one.

“I have probably attended as many deaths as I have births,” she said when asked recently about her relationship with patients. “I find the similarities uncanny. There is a sacredness that surrounds them both. A good birth and a good death are filled with the same ingredients – laughter, tears, peacefulness, joy, love and an incredible sense of awe. My purpose has been to help guide my patients through these transitions.”

Everyone will die, it is only a question of when and from what. We need to continue to better understand how to help patients through this inevitable transition, and somehow rescue this inevitability of life from the bitter politics of health reform.

DT