Hospice and its role in the health system

The WSJ has a piece focusing on the increasing use of hospice among Medicare beneficiaries with dementia that observes that the long stays of such patients has increased the cost to Medicare as compared to the shorter, more predictable stays by persons with cancer, for example.

Between 2005 and 2013, about 107,000 patients received hospice care for an average of nearly 1,000 days spread out over four or more calendar years, according to a Wall Street Journal analysis of Medicare billing records. They cost Medicare 14% of its overall hospice spending, even though they accounted for just 1.3% of its hospice patients.

Undoubtedly true, but what does that mean?

Here is a paper published 12 years ago noting the problem of the poor quality of life of patients dying with dementia, and suggesting that hospice could care for patients with more than just cancer. We addressed one problem (poor quality of life for those dying with dementia) and created another (longer stays in hospice for patients with dementia). And the cost issue that is the hook of the WSJ piece has always been paramount for hospice because it was sold in the early 1980s at least partly based on its ability to reduce costs as compared to normal care, which has been shown to be the case for more traditional hospice users (but not for very long users). Cost is a fair metric, but why should hospice be the only part of the Medicare program expected to improve quality of life and save costs? That is quite a standard.

The problem that is missed in the WSJ framing is that the United States does not have a coherent long term care financing approach (there are echoes of this in the story–but it is the most important thing to understand about this story in my opinion).

Families self finance LTC with their wealth and time, and when there is no more wealth, Medicaid pays for the elderly to live in a nursing home until they die. There are myriad problems with this approach, and Medicaid pays for about half of all nursing home days in the United States. The lack of a coherent LTC system in this U.S. shows up in all sorts of places–long hospice stays, readmission rates, persons in NHs when they could be cared for at home, etc. and we try to fashion fixes for these ‘canaries in the mine’ that miss the underlying problem.

Long periods of hospice use for home based patients with dementia (and other diseases) are more directly signals of the lack of a coherent LTC financing approach. The WSJ highlights such a patient:

Helen Blincoe, a 100-year-old from Loma Linda, Calif., bounced in and out of hospice care from 2009 until last year. Currently, her main health problem is dementia, and she is in relatively stable condition. On a recent day, she sat upright in an easy chair, her walker nearby.

During the nearly 850 days she spent in hospice care, her services consisted mostly of visits by home-health aides. Nurses and social workers also saw her, but less frequently.

Hospice was not envisioned for an 850 day stay. The country has most certainly not envisioned how 70 year old daughters care for their 100 year old Mother who is a widow. I will go out on a limb and say that the hospice care paid for this person is almost certainly the most valuable thing the Medicare program could pay for on her behalf. The fact that her care doesn’t fit into the Medicare hospice benefit and that there is not a ‘high touch, low tech’ LTC benefit shows that Medicare’s benefit package doesn’t cover what is most important for many of its beneficiaries.

What to do? A preferable approach would be flexibly provided support that enabled patients to stay in their home, likely reimbursed at a lower per diem rate than what hospice pays per day. Covering what I call “high touch, low tech” home based services are what many elderly persons need, and past work we have done at Duke suggests Medicare beneficiaries would be willing to forego some medical treatments to get such care.

Hospice isn’t perfect, but the most obvious warts are at least partly driven by having the health insurer of elderly persons in the U.S. not cover LTC. We need to address this problem head on.

 

 

 

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.

Impact of hospice on costs for patients in Nursing Homes

A new study by Pedro Gozalo and colleagues from Brown finds that Medicare beneficiaries who die in nursing homes have less intensive treatment in the last year of life, but the overall cost to Medicare of their care in the last year of their life, is higher.

Some key bullet points and issues:

  • What did they find? Hospice was associated with less hospitalization and fewer ICU days during the last year of life, but higher overall costs incurred by the Medicare program (around $6,700 more).
  • What didn’t they study? The impact of hospice on quality of life of the patients (at least directly; you could normatively infer benefit from less ICU use and hospital days; they discuss this), or families. However, they were using Medicare claims that don’t measure such variables.
  • What is new about the study? They use a clever, three part counterfactual strategy to identify the impact of hospice on costs. A key issue in observational assessments of the impact of hospice on cost is that persons who choose hospice differ from those who do not. Past work (our study from 2007; Amy Kelley’s from 2013) has used cross-sectional matching using observed variables to identify the most relevant comparisons to hospice users in order to isolate the hospice impact. Gozalo et al. use traditional observed covariate matching as well (part 1) but within a difference-in-difference approach (part 2) that takes advantage of secular trends in hospice use from 2004 to 2009 (much more likely later) to isolate the impact of hospice on Medicare costs. In short, there are decedents in 2004 who did not use hospice who would have done so under 2009 rates, and vice versa. This allows for isolating the impact of hospice on costs in 2009 on persons who were “new” users due to increasing use rates as compared to those who would have used hospice even without an increase. The same comparison is done in 2004, and the difference in the difference provides the estimated impact of hospice on costs. Finally, because all the subjects lived in Nursing Homes (NH), some variables like DNR or do not hospitalize orders that are unobserved but important are available for matching (part 3).
  • Who did they study? All subjects lived in Nursing Homes. This is a key contextual variable, and one that is missed if you say “this study shows hospice increases Medicare costs” because it is found to increase Medicare costs only among persons who died in NH. Most persons receive hospice in their homes, but the subgroup of those receiving it in NHs may be key from a cost standpoint.
  • Around 6 in 10 subjects had dementia, the disease associated with the longest period of hospice use in this as well as past studies. This is largely due to the unpredictability of death (as compared to other primary diagnoses) and does not invalidate the study by any stretch, but it helps to highlight the study patients. The hospice benefit has had a per diem payment that was not modified by diagnosis since its inception in 1983. The general trend toward increasing use of hospice, which has meant an increase in dementia as a primary diagnosis, along with a related increase in hospice length of use for dementia that has been widely noted, really signals that a disease specific hospice benefit may be needed if cost is a concern.
  • Last year of life costs are an easy concept to grasp, but may not be the best way to assess the impact on hospice on Medicare costs. The limitations of cross-sectional propensity score matching such as what I and colleagues used in a 2007 paper deserve to be noted (Amy Kelley et al added covariates, but has the same general problem), but the focus on measuring cost of cases (hospice) and controls (not hospice) from the point of hospice initiation until death strikes me as a more precise means of estimating the impact of hospice (regardless of how the counterfactual used to identify cases and controls is constructed). Further, the savings identified in past work accrues primarily in the last few weeks prior to death, and it seems conceptually suspect to infer that something used for 90 days should reduce cost over the last 365 days of life. It is a fair point to say that in our paper as well as Amy Kelley’s, all cases of hospice do not match to “statistically good” controls but Medicare has to pay for the care for all patients, but the same can be said for the new paper as well. Pedro and colleagues rightly note that the last year of life is a commonly used time frame, but that doesn’t do away with this conceptual issue. It is an interesting conceptual discussion about the appropriate dependent variable for such a study: full last year of life costs or costs from the date of hospice initiation until death. To push it ahead, I would just like to see more analysis. Pedro and colleagues could update their estimates using the approach that we used and that Amy Kelley etc followed–measuring savings (or not) from the onset of hospice to death and assess their cost findings.

This is an important paper with a very clever estimation strategy, that deserves to be discussed, technically and conceptually (especially my last point above), as well as for what it might mean in terms of policy adjustments. I will have some thoughts on this in a follow up post.

Hospice enrolling well patients to kill them?

The online headline of the WaPos latest on the Medicare hospice benefit (in fairness to the author, they typically don’t have control over headlines; but the article itself has such competing themes, it would be hard to figure out the headline):

Lethal doses: the dangers of hospice care

The hospice industry is booming, but concerns are rising about treatments for patients who aren’t near death.

If you stopped at the headline, and sub-headline you would get several ideas:

  • Hospice is enrolling patients who aren’t dying
  • Lethal doses of medicines are being given, meaning either euthanasia or homicide is occurring (depending upon the state there is no legal difference between the two)
  • Hospice is booming, presumably due to enrolling and then killing patients who aren’t dying

Not sure where to start, so I will just make a few points (busy day).

  • There are legitimate worries about long hospice stays, particularly that go beyond the presumptive period of 180 eligibility for hospice. But, the business model for hospices getting rich by enrolling non dying patients into hospice is not to kill them, but to bill Medicare for their care for a long time. Hospice is reimbursed on a per diem amount. The financial maximization incentive is to serve them longer, not shorter. Long hospice stays are a problem, but this article’s mashup of enrolling patients who aren’t dying to get rich and then killing them quickly makes no logical sense together.
  • There are some very bad stories in this article. At least one of them is essentially an accusation of homicide. If I talked to a reporter about the care described, I would definitely take the next step and talk to the district attorney in the county in question.
  • There is a story of a patient getting better, but the hospice continuing to provide care without acknowledging this reality and continuing to provide hospice. This is one example of the traditional long stay hospice concern. Purposefully giving your patients fatal overdoses is directly contra to the financial motive of wanting to bill Medicare for a long time for patients who don’t need hospice.

To say that this article went for the sensational is a bit of an understatement. However, it bizarrely throws together different types of sensational narratives in a way that makes little sense. They are bilking Medicare via long stays! They are killing their patients with overdose! Logically, there could of course be examples of both, but this story does not do a good job of setting these cases against the general context of hospice care. And given that this is a part of a series on hospice, I would expect better in a newspaper of this stature.  

CMS Revises Part D/Hospice Guidance

CMS today revised its guidance on procedures related to determining who pays for pharmaceuticals used by Medicare beneficiaries who elect hospice care. A hospice is responsible for paying for all drugs related to the terminal illness under Medicare regulations, a fact that was never in disupute conceptually. However, the March 2014 guidance that was aimed at ensuring that Medicare was not “double paying” for drugs (which would occur if Part D plans were billed for drugs that should be financed via Medicare’s per diem payment to hospice providers), had lead to gaps in the prescription for pain and other medications as patients trasnitioned from normal care into hospice, leading some patients to disenroll form hospice, or to needlessly suffer.

Specifically, the new guidance reduces the classes of pharmaceuticals that Part D plans must require prior authorization prior to filling once patients elect the hospice benefit in Medicare. These drugs groups: pain, anti-nauseants, anti-anxiety and anti-consitpation medications are they are groups of drugs that are almost always  a part of a hospice patients care regimen due to the common end of life symptom of pain, and dealing with the side effects of addressing pain using pharmaceuticals.

This is a common sense tweak to of a rule to address an unintended consequence of a legtitmate effort to ensure that Medicare does not double pay for drugs.

More on hospice reform

The WaPo had an interesting article (leaving aside the needlessly sensational headline) noting that 1 in 6 hospices that served 50,000 Medicare beneficiaries who died provided no continuous home care (extra care when patients have very high needs implemented by hourly payment increases, typically just before death) or Inpatient hospice care (again, a higher acuity setting; most get hospice in the home, but there are facilities).

The worry is that some hospices are either (1) not adequately serving some patients, or (2) that they are enrolling patients into hospice who may not fit the parameters of the benefit. A few thoughts on this, which is another piece of information that is likely to help us creep toward some consequential reform of the hospice payment approach in Medicare.

  • This statement from the National Hospice and Palliative Care Organization (NHPCO) is the clearest statement I have seen from them saying that hospice providers who are unable to deliver the entirety of the hospice benefit package in Medicare shouldn’t be allowed to do so in a partial manner. The first sentence of the statement sets the tone, and this statement is a subtly important public moment that will enable more aggressive change:

“There are two kinds of hospices in America: the ones that get it right, and those that should be out of business. “

  • On hospices not ever delivering inpatient hospice care, I have heard some smaller, often rural hospices lament that larger inpatient facilities will not provide them with a contract that lets them avail themselves of the inpatient unit. There can be similar issues with hospital based inpatient units as well as with nursing homes. And if a state is a certificate of need state, the hospice cannot build a facility. The hospice industry is ripe for cosolidation, and (lack of) access to inpatient hospice facilities in some areas will help to drive it, especially with this increased attention.
  • The groups of hospices who are not providing any continuous home care hospice coverage is a trickier group. First, it seems unlikely, but not literally impossible, that a hospice would never have a single patient needing around the clock care in the last few days or hours of someones life. This raises quality concerns for patients in a given hospice, and also for those who may be unserved due to inability to meet patient needs. This is pure hospice policy. Second, some hospices in this category may essentially be providing a back door long term care (LTC) benefit. And backdoor LTC being provided via the hospice benefit in this manner could be more valuable to patients and families than anything else that Medicare is paying for; however, that is not what the hospice benefit regulations allow.

We need to sort through these issues and reform the hospice payment and enrollment system in the Medicare program. Following the rules is important. We need to also listen up for signals that the rules may need to be changed. When teaching Intro to the U.S. Health System at Duke from 1999 to 2003, I used to say the biggest hole in the benefit package was prescription drugs and LTC. Now I say it is LTC.

The lack of a coherent LTC system in the U.S. has spillover effects into all sorts of Medicare policy, including hospice (e.g, long stays more likely debility/dementia). It would be better to address these head on.

CMS proposed hospice payment rule for FY 2015

CMS released their proposed hospice payment rule for fiscal year 2015, yesterday. Highlights:

  • 1.3% increase of hospice per diem payments
  • proposes clarifying the “terminal illness” requirement to elect hospice. The primary change would be to allow for consideration of patient functioning/co-morbidity in determining eligibility as opposed to a singular focus on prognosis
  • proposes setting a 3-day time limit by which a patient must file notice of “hospice election” which means they are un-electing “curative” care that is covered by Medicare. The current standard requires “timely” notification, and in some cases that has taken up to 10 days. The point is that Medicare can be paying for both hospice and “curative” care during this interval which would now be formalized.
  • files notice to clarify what physician is the primary medical provider for billing purposes (to be defined by the patient/decision maker). In the past, multiple physicians have billed as the primary medical provider.

The payment update is straightforward and is most notable for what it is not (a re-basing similar to home health, or a u shape payment with higher payments earlier and later in a stay, but lower in the middle). The other items are a series of policies that could be understood as pre-cursors to more fundamental reform (clarifying what physician is viewed by the patient as their primary doctor, and setting a clear period of time by which notice of hospice election must be filed). Further, the quality reporting requirements for hospice that were brought about by the ACA will be coming online this year, which is a key component for evaluating future payment policy changes; a baseline will be collected this coming year. The most interesting aspect of the rule for me is the clear statement of importance of palliative care, and noting hospice as a subset of palliative care. I am not sure I have seen CMS write about this relationship so clearly in the context of setting hospice policy, and there are many barriers to the financing of palliative care in the Medicare program when a beneficiary is not terminally ill based on Medicare regulations.

The payment update will likely get the focus on this proposed rule, but the other items and tenor of the document portend more consequential changes coming down the road, likely including facilitation of non-hospice palliative care.

More on hospice concurrent care

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.