CMMI Palliative Care Project

We have a piece in Health Affairs blog describing our Center for Medicare and Medicaid Innovation (CMMI) grant in Palliative Care. We are working with Four Seasons Hospice who is providing care in this model in Western, North Carolina and down into South Carolina. We will be receiving Medicare claims for the first two years of the project in the next month, so should have some sense of the cost before, during and after (most typically hospice election) the palliative care program.

The table below frames the policy landscape for Palliative Care financing in the Medicare program. A key part of the CMMI project will be to propose the outline of how Medicare payments should be changed to facilitate more provision of Palliative Care, including considering the development of an Alternative Payment Model (APM).

A key aspect of this discussion is what type of health care organization can provide all of the care encompassed in a Palliative Care Benefit, and how the creation of new payments approaches can be flexible across different types of local health care delivery markets.

Table 1. Policy Landscape For Financing Palliative Care Services At End Of Life In Medicare

Medicare Benefit
Part A
Hospital Insurance
Part B
Physician Services
(Medical Insurance)
Part C
Commercial Medicare Advantage
Part D
Prescription Drug Coverage
Financing Trust Fund payroll tax and other sources Premiums with deductibles and general revenue (income tax) Commercial premiums with deductibles General revenue (income tax) & premiums with state contributions
Services Hospital, skilled nursing, long-term care, hospice Doctor visits, lab services, durable medical equipment, therapy Private A + B + (D) + additional benefits
• 30 percent population
• Hospice carved out
Prescription drugs
Cost triggers Reduce unnecessary utilization Increase care coordination and goals of care Unknown; unavailable claims for research Symptom management outlay vs. curative
Current movement Hospice “two-tiered” payments with service intensity last seven days Advanced Care Planning CPT codes

Transitioned Care Management codes

Chronic Care Management PBPM

PILOT: Medicare Care Choices Model (test $400 PBPM concurrent care for hospice-eligible beneficiaries)

Aetna Compassionate Care program for under 65 commercial

Numerous proprietary coordinated/ palliative care management programs underway

Review of access, medication reconciliation, polypharmacy, and discontinuation issues
Potential bundles as APM Hospital-based palliative care services

Post-acute care (90-180 days) prior to hospice palliative care services

Primary care (CCM, CPC+, PCMH medical homes) additive for palliative services in PBPM

Specialty care (CCM, medical home) additive in PBPM

Proprietary build on HCC risk score methodology Pharmacy/drug benefit during episode transitions (90-180 days) prior to hospice
Implication of ACO-MSSP Provider groups managing Total Cost of Care (Parts A, B, D) with increasing risk models and flexibility to deliver care across settings where financial control can be leveraged Excluded from MSSP; MA program innovation increasing but not publically shared Clustered resourcing as part of Total Cost of Care

Abbreviations: ACO=accountable care organization; APM=alternative payment model; CCM=chronic care management; CPC+=comprehensive primary care plus; HCC=Hierarchical Condition Category; MSSP=Medicare Shared Savings Program PCMH=patient-centered medical home; PBPM=per-beneficiary per-month

CMMI Round 2 Grant Announcement

The Centers for Medicare and Medicaid Services Innovation Center (CMMI) today announced 12 organizations as prospective recipients of round 2 innovation grants; other projects will be announced later this Summer.

I am thrilled to be working on one of the 12 projects identified today.

FOUR SEASONS COMPASSION FOR LIFE

Project Title: “Increasing patient and system value with community based palliative care”
Geographic Reach: North Carolina
Estimated Funding Amount: $9,596,123

Summary:

The Four Seasons Compassion for Life project will test a new model for community-based palliative care (in conjunction with Duke University), which spans inpatient and outpatient settings. The model features interdisciplinary collaboration and the integration of palliative care into the health care system, continuity of care across transitions, and longitudinal, individualized support for patients and families. This expands upon a successful program in four Western North Carolina counties to include an additional ten counties.  With community-based palliative care, care coordination ensures clinical follow-up of patients as they transition across settings. Standardized assessments and data infrastructure facilitate quality monitoring/improvement and high-quality patient care leading to decreased hospital readmissions.

I am the lead investigator of the Duke project team. We will work to measure both the quality and financial outcomes of the project, and develop new financing models for how the Medicare program pays for the care of beneficiaries with advanced, life limiting illness. This project is a dream come true for me: joining high quality data and research techniques with a funding mechanism that insists on policy translation/impact as the ultimate outcome. I cannot wait to get started.

The collaborative nature of this project is also a model, both within Duke and between Duke and Four Seasons. The Duke team joins the Sanford School of Public Policy with the Duke Center for Learning Health Care (CLHC), part of the Duke Clinical Research Institute (DCRI), lead by Amy Abernethy, who is the past president of the American Academy of Hospice and Palliative Medicine and an incredible colleague. The proposal was very complex, and Matthew Harker at CLHC melds business savvy, organizational and grantsmanship skills with an abiding interest in caring for people who are extremely ill, and we would not have pulled it off without him working so well with Chris Comeaux, CEO/President of Four Seasons and the rest of their team.

The seeds of this project were planted a decade ago, when Janet Bull, medical director of Four Seasons and Amy Abernethy began a unique academic-business partnership that has resulted in many projects and a model interaction between a community based hospice and palliative care provider and an academic medical center and university.

I am very fortunate to be part of such a team.

CMMI proposal on Community Based Palliative Care

Blogging was non-existent this week because I was working on a huge CMMI grant that was due yesterday. We (myself + Amy Abernethy at Duke and our long time partners Four Seasons Hospice and Palliative Care, lead by Janet Bull) are proposing to expand the Four Seasons Community-Based Palliative Care (CPC) model that is running in 4 Western, North Carolina counties to 14 counties, and to evaluate the impact (N=10,000 patients/3 years) on patient outcomes and cost.

From this evidence base, we will develop a new financing approach for CPC in the Medicare program (we plan to develop both a transitional fee for service approach designed to make CPC a break even propostion (it is now a $ loser), as well as a fully bundled/capitated payment approach that would reduce overall Medicare costs and allow for shared savings, as the long run goal). The ability to work with such great colleagues on issues of consequence is very exciting.

Time & Motion Study of Community Based Palliative Care

We have a new paper (open access) in the Journal of Palliative Medicine, providing a Time and Motion study overview of the care delivery model at the heart of our CMMI HCIA-2 innovation award with Four Seasons Hospice in Western, North Carolina (Janet Bull, who is also President of the American Academy of Hospice and Palliative Medicine and I are the co-PIs of the project).

This figure provides an overview of the palliative care model that we are providing across setting (~5,000 patients will enrolled by the end of Summer, 2017, and we just received Medicare claims records for the first 2+ years of the project, so should have preliminary cost findings in the Fall).

TimeandMotion.6.6.17jpm.2016

 

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.

CMS Concurrent Hospice Demo

CMS has announced the hospice concurrent care demonstration that I blogged about in March 2014. The big idea in concurrent hospice care is that people can receive services from a hospice provider without having to “unelect” curative treatments, which has been required to receive hospice since 1983. Concurrent palliative care was one of three “non covered” benefits that around half of Medicare beneficiaries said they would fund via reductions of other care in some of my past work. This is not exactly that, however, because the demo announced yesterday requires that a patient be hospice-eligible, which means a physician certifies they are likely to die within 6 months.

A few thoughts on this.

  • Cudos to Medicare for innovating. In hospice, Medicare has always led the way, and will do so again. Further, over 8 in 10 people who die annually in the U.S. are Medicare beneficiaries, so getting end of life care straight in Medicare is key.
  • The biggest limitation to the demo is the fact that patients must be hospice eligible (a physician must say they are likely to die within 6 months). I would prefer to see a concurrent demo that attempted to push further up the disease course, say to the last 12-15 months of life.
  • Because a patient is hospice eligible, the $400 payment that hospice providers receive per month, is less than what they would receive in roughly 3 days of providing full fledged hospice care (after unelection of curative). Since the patient is able to continue receiving curative care, the notion is the services provided by hospice providers will be less intensive. However, my read is that the hospice is on the hook for delivering all of the hospice benefit. One thing to watch in the evaluation: how many patients start this and later stop the hospice concurrent care demo because they want more care than perhaps the hospice planned to provide (I think most hospice providers will do phone based monitoring, but we will see what happens).
  • In one sense it is surprising so many hospice providers applied. There was much grousing about the low payment and fact that providers have to be prepared to deliver the full hospice benefit. However, I think many thought they needed to be involved in such a demo, and the general concept of concurrent care is the way most who look closely think this end of life care should go.
  • Another key metric for the demo will be conversion rate of patients who start this demo into full-fledged hospice. In one sense, why would they? However, hospice providers will have lots of incentive to get them to do so, both due to payment and their normative belief that what they do is best for dying patients.
  • The evaluation design presents lots of interesting opportunities. Demo hospice providers, hospices who wanted to participate and weren’t selected, and other providers. Non experimental inference is key for policy research and this will be an interesting one from a methodological perspective.
  • We have a CMMI demonstration of early palliative care (further up the disease course) with Four Seasons Hospice and we are attempting to evaluate the impact on quality and cost to Medicare of this model (CMMI billboard May 16). The announcement that Medicare will begin paying for advanced care planning in January introduced an intervention into our control group, and maybe even the demo. There there is another new intervention to be accounted for.

New MEDPAC study says some past work (mine) overstates hospice savings

A MEDPAC contractor report considered the question of “does hospice reduce Medicare costs?” from three perspectives, and concluded that a matched-control approach that only compares costs from the time of hospice initiation to death overstates savings. This is the approach that we used in 2007, and that was replicated (and improved upon in terms of covariates) by Amy Kelley and colleagues in 2013.

The essence of the approach we used is to take hospice decedents, match them to otherwise statistically similar decedents, and then compare costs for the period of hospice use (if used for 10 days, compare only last 10 days of life).

I will blog more about this next week, but a couple of quick thoughts:

  • The MEDPAC report notes that the methods we used to pick a control group and that Amy Kelley adapted are not the most appropriate way to address the question “does hospice reduce Medicare spending?” I think the method we used is better than that alternatives, but I want to leave that aside for a second and say that all of the action in a non-experimental study of this type is how you pick the control group. As compared to what? is always the most important policy question.
  • In our ongoing work on palliative care, we are planning to use multiple methods of picking a control group, and further plan to think deeply about why the answer to the seemingly simple cost saving question can differ so much by method. There is information in this uncertainty, and non experimental inference is just about the most important thing for policy evaluation that will never be subjected to a randomized trial.
  • The answer to the question could differ by market area, as well as across time as an area becomes “fully exposed” to hospice and palliative care concepts. This part of the report (that I have not read carefully yet) looks to be very important. It is hard to think that the early hospice cost assessments that looked at the last year of life–for example–when the median stay was 15 days is the best way to evaluate this question. A market approach might be better.
  • I agree with MEDPAC that cost savings is not the most important question to address. Here is a list of many others.
  • Non experimental policy evaluation is hard. On January 1, 2016, about halfway through our CMMI project, Medicare will start to finance advance care planning. That means any control group in the last 18 months of our study had ready access to a key palliative care intervention that was not present from the beginning. I am not sure exactly what the answer to all these questions are, but I am confident that more data is better than less.

Medicare will pay docs to discuss dying

Medicare announced today that it will pay physicians to discuss dying, and the preferences, choices and options that patients have when they face the inevitable (it is only a matter of when, and from what). Six Augusts ago, the summer congressional recess exploded into “death panels” as a way to argue against the ACA. The offending provision would have simply paid physicians to have this type of planning discussion. Five Augusts ago, a RCT of early palliative care showed that patients with stage-4 lung cancer who essentially had such “goals of care” discussions–but who could subsequently choose whatever care options they wanted–actually lived longer, had better quality of life and cost a little less as compared to those who did not have such a discussion.

The idea that Medicare wouldn’t pay for a discussion of preferences and options for patients is absurd since over 8 in 10 persons who died last year in the U.S. were insured by the program. Medicare is inherently in the dying business, and each of us will do it once. The policy announced today will allow physicians to get paid to have goals of care discussions with patients and family members (see p 246), which is important to help patients to make the most informed choice possible. This policy represents a small step toward sanity in this area.

We at Duke have a Center for Medicare and Medicaid Innovation Award on palliative care with Four Seasons, which is seeking more to develop more comprehensive payment changes to how the Medicare program pays for end of life care, but we are still early days in the project (CMMI billboard May 16).

Post Doc Position in Health Policy at Duke

I am searching for a post-doctoral research fellow at Duke; I will be the primary supervisor of the fellow. The Post Doctoral Fellowship Description.4.13.15 is also pasted below.

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

Post-Doctoral Fellowship in Health Policy and Health Services Research

Duke Clinical Research Institute (DCRI), Duke University

*************************************************************************************

The Duke Clinical Research Institute (DCRI) seeks a full-time Post-Doctoral Research Fellow with training in Health Policy, Health Services Research, Public Policy, Epidemiology, Informatics/Statistics, Economics, Sociology or related discipline. The successful candidate will join a multi-disciplinary team of investigators working on a variety of policy-relevant projects, with a focus on projects that are seeking to develop new models of delivering care to persons with advanced, life limiting illness. The goal of the fellowship is to advance the intellectual and professional development of the fellow as they transition toward being an independent researcher.

Funding, Role and Primary Tasks:

  • Funded 100% by the Duke Center for Medicare and Medicaid Innovation (CMMI) Award that is demonstrating Community Based Palliative Care and assessing its impact on patient outcomes and costs to the Medicare program and developing new ways for the Medicare program paying for palliative care services. Funding can remain 100% on this project for 2 years. There will also be options to shift funding to other projects based on shared interests.
  • The CMMI Innovation award is a demonstration project that is being implemented in 12 Western North Carolina counties by Four Seasons Hospice, and Duke’s role in the project includes collection of quality monitoring data; assessment of the acceptability of palliative care to patients, providers and others; linking demonstration data with Medicare claims records using Duke’s Virtual Data Research Center (VRDC) which is a secure linkage that allows access to CMS data; identifying propensity score matched controls to allow for assessment of the impact of palliative care on cost to Medicare; the extrapolation of the impact of palliative care on Medicare costs to simulate the impact of broad uptake of palliative care nationally; and development of proposed modifications to the existing Medicare payment structure in order to incentivize the increased use of palliative care. The post-doctoral fellow will work on all aspects of this project described, working as a member of a growing interdisciplinary team.
  • The purpose of the post-doctoral fellowship is to both complete the work of the CMMI innovation award as well to assist the fellow in developing their own research agenda. This will include working on grant proposals that are of mutual interest to the DCRI and the fellow.

There are opportunities for the fellow to transition into a faculty position in one of several departments at the Duke Clinical Research Institute (DCRI), Duke University School of Medicine, Duke University and/or the Duke University Health Care System. Salary is commensurate with experience and background, and includes the full Duke University benefit package. The fellowship is open immediately.

The fellow will be supervised by Donald H. Taylor, Jr. Ph.D., Professor of Public Policy, Duke University and Faculty member, Duke Clinical Research Institute (DCRI). To apply, please send a CV, a cover letter outlining the candidate’s interests, and the names and contact information of 3 references. Please send materials via email to Don Taylor (don.taylor@duke.edu) and Abby Hardaway (abigail.hardaway@dm.duke.edu) with DCRI Post Doc in the message line with the noted items attached. The post is open until filled.

Cost v value as policy focus

Ezra Klein has a nice post running over the political and policy problems of focusing on “cost reduction” in health care, and instead suggest focusing on the receipt of value for the dollars spent. He frames the decision in partisan terms–what should the guiding health policy be for the Ds as opposed to the Rs, but there are some limitations to a cost focused strategy in policy terms, even if you believe the health system is unsustainable.

Two questions are paramount here. The first is what is the appropriate out of pocket exposure that an individual should face prior to receiving care? Does it differ by age? Income? Health Status? You tell me….The problem with blunt tools like large deductibles is that they likely reduce good and bad spending (high value and low or no value). The roll out of the ACA has helped to crystallize this question, if only we could get to the policy and off of the macro political narrative.

The second question (how to get to higher value for the dollars spent?) is laid out in some of our recent work at Duke looking at the preferences of Medicare beneficiaries who have cancer. Simply put, could expanded patient and family choice in they types of care covered  by the program (that pays for the care of 8 in 10 persons who die each year) lead to a more productive expenditure of resources? And in doing so, possibly reach what sounds too good to be true–lower spending with higher benefit to patients? We are about 3 months into enrolling patients into a Center for Medicare and Medicaid Innovation Center grant (CMMI) to demonstrate, evaluate and propose potential payment changes for how Medicare reimburses palliative care. This feels like it might be the most important work I might do in my professional career. If you change the incentives in how Medicare pays for end of life care, it will filter down into the rest of the health care system.

I am at the American Academy of Hospice and Palliative Medicine Annual Assembly (follow #HPM15) in Philly for the next two days, and many parts of the questions and answers under the “value proposition” will be on display here. We as a field (hospice and palliative care) need to do a better job of translating the research evidence base into usable information for policy makers. I think the country is ready to listen, with IOM report Dying in America helping in this manner. When will the political system be ready for the next steps in health policy? (and the next, and the next?, etc)). Not sure, but we need to be ready to lead into the most difficult health policy questions when they are, and the biggest goal–focusing on maximizing value for the health care dollars we spend.