Talking Medicare End of Life Policy Changes

I was on WUNC’s program The State of Things yesterday talking about changes to Medicare end of life policy. About 12 minutes.

Right to Die Debate

Most of my research focuses on hospice and palliative care–so I think, study and talk a great deal about death. Invariably when I give a talk about hospice and palliative care policy, someone asks about physician assisted suicide. This surprises me because I see them as quite different, but I guess it shouldn’t since it keeps happening, especially if non researchers (normal people) are in the audience.

A flip response by someone (me) who feels quite morally muddled about physician suicide is to say something like “if we have better hospice and palliative care, then no one would be interested in physician assisted suicide.” I have said this in response to questions about physician assisted suicide and the right to die movement, but I don’t really think I fully believe this to be true.

I remain muddled on this issue, however, I do think this piece by Kevin Drum is the most coherent and honest thing I have ever read on the topic and I commend it to you.

 

Evaluating Medicare End of Life Changes Coming 1/1/2016

We have a post at Health Affairs blog on 3 changes to Medicare end of life policy that are taking place on January 1, 2016:

  • First change in how Medicare pays hospice providers in 32 years
  • Payment for Advance Care Planning
  • The Medicare Choices program (test of concurrent hospice care)

Any one of these would arguable be the biggest end of life policy change for Medicare since the creation of the hospice benefit in 1983; combined, they make for huge shift, and evaluating their impact is a top policy priority.

Should Hospice be put into Medicare Advantage?

The bipartisan Chronic Care Working Group of the Senate Finance Committee outlines this as an option they are considering (see p. 8 h/t to Brad Flansbaum). I have blogged about the oddity of hospice being carved out of Medicare Advantage plans before (here, here, and here). Several points:

  • There is no actuarial reason to carve hospice out.
  • Putting hospice into the Medicare Advantage benefit package will almost certainly lead to hospice aggregation and driving out small providers in some areas, because hospice is now any willing provider in Part A. If we put it into Med Advantage plans, they will contract and in some markets this will have big impacts. This might be good and might be bad depending on the market (competition v quality trade-off).
  • There is now a huge business opportunity produced by this carve out that is just now being leveraged. Any palliative care company that can (1) get more Medicare Advantage patients to elect hospice and (2) do so earlier will improve Med Advantage plan profitability. If a patient goes out of Med Advantage to hospice 30 days before death versus dying in a hospital, the Med Advantage plan losses ~$1,500 in premiums, but avoids $15,000+ in claims. They likely improve patient quality/experience as well, but these profits now could at least partly be going back into the system.

My guess is that hospice goes into the Medicare Advantage benefit package within the next few years, driven finally by the rise of palliative care on a more widespread basis.

Beyond this issue, the working paper is filled with what interests a bipartisan group of staffers + members of the Senate Finance Committee (they key committee) in the area of chronic care, so this is a great place to start when thinking about what you should be studying/writing a dissertation or grant on.

Five Most Pressing End of Life Science Policy Needs

A colleague from a federal funding agency asked me last week for a “10,000 foot view of what you feel are the five most pressing science policy issues for palliative, hospice, end-of-life areas?”

Here goes.

  • How to better represent uncertainty (prognosis, treatment effectivenss, etc) to patients and families
  • Aligning patient/family wishes and preferences with treatment options offered (at both a micro level—as patients go through illness trajectory as well as in structuring what is offered to patients in benefit packages)
  • Improving methods of non experimental inference, which includes reaching a societal consensus on ‘how much evidence is good enough?’ to make policy decisions based on observational demonstration evidence
  • Improving prognosis methods, and including morbidity/disability states as both an outcome of interest, as well as using same to better predicting survival
  • Harvesting and providing data on cost, quality and patient/family preferences in near real time so that it can be used to inform treatment decisions

A Beautiful Death

That is the name of the Duke Sanford Schools newest “Ways and Means” podcast that discusses one families struggle with brain Cancer, with some extended comments from me on the subject of what Medicare does and does not cover for persons facing the end of their life.

Medicare doesn’t cover stuff really important to old people

Katy Butler describes the end of her Father’s life, and laments that the Medicare program will pay endlessly for high tech treatments with little chance of success, but does not cover high touch, low tech long term care that could keep patients comfortable in their homes.

A paper from last year shows that around half of Medicare beneficiaries with Cancer and their families would be willing to reallocate some of their entitlement away from last ditch chemo and the like, and toward high touch, low tech care designed to improve quality of life for patients and family.

The gaps we highlight show beneficiaries and caregivers allocating finite resources toward now-uncovered benefits that broadly speaking are designed to maximize quality of life:

Highlights of a prior post on this study (JCO-2014-Taylor-3163-8).

  • unrestricted cash  (some level chosen by 46%)
  • home based long term care (52% choose a level far beyond what home health would cover)
  • concurrent palliative care (45% chose a level beyond the current hospice benefit; such care without having to unelect curative treatments)

The numbers highlighted in yellow (from Table 3 in the paper) correspond to the text just above, and show the distribution of subjects choosing benefits not now covered by Medicare at the initial assessment in the study (subjects did multiple assessments; their selection of non covered benefits was relatively stable before and after facilitated discussions).

ScreenHunter_02 Aug. 25 16.17

The key to our study (there are limitations) was that the above results represent patients and families saying they would reallocate finite resources away from the current Medicare benefit package, and toward these other 3 hypothetical benefits; they were not just adding these on top of everything else.

The most important thing not being discussed in the Presidential election is how our society will address the long term care needs of the baby boomers. Patients and families, with better information and more choices in how they consume their Medicare entitlement, could lead to a partial solution, within the planned aggregate spending of the Medicare program.

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*Donald H. Taylor, Jr., Marion Danis, S. Yousuf Zafar, Lynn J. Howie, Gregory P. Samsa, Steven P. Wolf, Amy P. Abernethy. There is a Mismatch Between the Medicare Benefit Package and the Preferences of Patients with Cancer and Their Caregivers. Journal of Clinical Oncology 2014; 32(28):3163-68.

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