More on hospice concurrent care
March 30, 2014 1 Comment
I spent a lot of last week in Washington DC, first at the Hospice Action Network event Tuesday on length of hospice use, and then being a part of the Friday research plenary at the National Hospice and Palliative Care Organization’s (NHPCO) Management and Leadership conference. There was a great deal of discussion of the recently announced CMMI Concurrent Hospice Demonstration program, and it is striking how little understanding there is in the field of exactly what the demonstration entails. A few quick thoughts:
- My understanding of the program as a essentially a test of the “Temel study” in which the $400/month would fund goals of care discussions and some phone monitoring, with hospices then able to bill the hospice per diem if they provided more care is wrong. The language about billing other parts of Medicare under Parts A, B and D seems to refer to, for example, the ability of a hospice to provide social worker care that could be billed separately to Part B. However, it is quite complicated to determine when that is allowable as a one-off, and many hospices are not set up to do this in the first place.
- One key issue in all this is inducement. We have generally spent lots of time worrying about providers inducing patients to receive further services provided by the same providers, but the goal of concurrent hospice seems to actually be inducement at some level (to get people to elect hospice who ohterwise would not have). Some new thinking on this general issue is needed with respect to hospice and palliative care.
- If it really is the case that you get $400/month and essentially are responsible for the entirety of the hospice benefit, then I don’t think anyone will apply for the demonstration.
- At the NHPCO meeting on Friday, an official from CMMI came and talked generally about the demonstration and the hospice benefit and industry. I heard him say fairly clearly that CMMI was open to more discussions about the shape of the concurrent care demonstration should take. Others seem to have heard differently. Some more refinement and discussion is needed.
- Keep in mind that patients have to be eligible for hospice to qualify for the demo, which means they can be certified as having less than 6 months of life. They are eligible to elect hospice at that point, but they have not chosen to do so. It is a good idea for CMMI to try out a new approach that allows for concurrent care for this group of patients to see if you can: (1) improve their quality of life; and (2) potentially increase their likelihood of electing hospice; and (3) potentially reduce costs even in the subset of patients who will not elect hospice. I know many are critical of the focus on hospice-eligible patients only because they believe concurrent hospice/palliative care should be pushed further up the disease course. I agree with them generally, however, but focusing a small intervention on patients who are hospice eligible but who have not elected it seems a reasonable place to start, if a plausible demo can be constructed.
- A key issue is what is it that participating hospice providers will be promising to patients, family members and the rest of the health care system for $400/month?
- Two options to push the conversation: First, hospice providers could describe what they could do for $400/month, and propose that to CMMI. Say clearly, here is what we could do for that. Is that what you want to try? And make clear that the constraint is what can be promised to patients, caregivers and the system. Second, propose a concurrent hospice model(s) for hospice-eligible patients, along with the financial resoruces that it would take to undertake a proposed demo. Simply say, we would love to try this; will you let us?
- I believe that a test of the Temel “early palliative” model that begins with a goals of care discussion, and proceeds with monitoring and information sharing, and integration of the hospice team into big decisions could be a fruitful approach, that is not risky in terms of the amount of money risked. The key is getting a realistic reimbursement level for the delivery of hospice/palliative services. There may be other models to test as well.
I give CMMI credit for rolling out this demonstration. However, I think it really needs to be the beginning of a more detailed discussion to identify the exact nature of what demos will actually be tried, and not the last word on the demo.