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

More on Advance Care Planning in Medicare

This article starts with the Death Panel nonsense, reignited by a Republican Party official in Florida last week, but the second half of the piece is a fairly good discussion of the issues around Advance Care Planning that the Medicare program began paying for January 1, 2016. Some of our recent work shows that the comment period held during 2015 for this pending change was not particularly controversial.

Forget about the nonsense, and read the discussion of the policy reality at stake.

A snippet:

The CMS rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions. The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians’ assistants may also seek payment for end-of-life talks.

End-of-life conversations have occurred in the past, but not as often as they should, said Paul Malley, president of Aging with Dignity, a Florida nonprofit. Many doctors aren’t trained to have such discussions and find them difficult to initiate.

“For a lot of health providers, we hear the concern that this is not why patients come to us,” he said. “They come to us looking to be cured, for hope. And it’s sensitive to talk about what happens if we can’t cure you.”

Further on the impact:

Proponents of advance care planning cheered evidence of the program’s early use as a sign of growing interest in late-stage life planning. Being able to bill makes a difference, Malley said.

The new reimbursement led Dr. Peter Sutherland, a family medicine physician in Morristown, Tenn., to schedule more end-of-life conversations with patients last year.

“They were very few and far between before,” he said. “They were usually hospice-specific.”

Now, he said, he has time to have thorough discussions with patients, including a 60-year-old woman whose recent complaints of back and shoulder pain turned out to be cancer that had metastasized to her lungs. In early January, he talked with an 84-year-old woman with Stage IV breast cancer.

“She didn’t understand what a living will was,” Sutherland said. “We went through all that. I had her daughter with her and we went through it all.”

Death panel nonsense back?

A Florida county Republican Party official said there were “death panels for Medicare beneficiaries over age 74” yesterday at a town hall meeting. There are not. Watching the video, it is unclear if the fellow was just saying something to try and make it through a meeting, or if he really believes this. Both are bad.

Just last week in BMJ Palliative Care (bmjspcare-2016-001182-bhavsar), we published an analysis of the federal register comments for the proposed rule (now policy since Jan 1, 2016) that let Medicare pay physicians for Advance Care Planning in which they discussed wishes and preferences with patients and family members. Very few of the comments submitted were negative, and we entitled the piece “The Death of Outrage Over Talking About Dying.”

Maybe we spoke too soon….

Nrupen A. Bhavsar, Sara Constand, Matthew Harker, Donald H. Taylor, Jr. The Death of Outrage Over Talking About Dying.BMJ Supportive and Palliative Care 2017;early online, accessed February 12, 2017.

What Should Health Insurance Cover?

This is a basic health reform question, and one knock against the ACA has been that the benefits are too generous, which drives up the cost of premiums. This WSJ piece provides a good overview of the issue (and tradeoffs), and has a nice graph showing what proportion of individually sold insurance plans included benefits that are required by the ACA. Changes to the benefits required in the ACA could be made via rulemaking (the law describes categories of benefits that were detailed via rulemaking), Congress could reduce benefits in some “replace” or “tweak” of the ACA, or the issue could be devolved to the states, also via a replace or tweak bill. It is easy to criticize in health reform, but improvements are hard, because of the tradeoffs.




The Case for Medicaid Expansion

I have a piece (caseformedicaidexpansion-1-23-17) in the latest issue of the North Carolina Medicaid Journal arguing for Medicaid expansion. I wrote it last fall and thought it was going to be out during the Fall. I updated it briefly earlier this month, by invoking a Meatloaf song. The piece is based on the ACA payment formula and the Urban Institute’s modelling of expansion uptake and costs that they completed late last Summer.

The looming Cassidy-Collins Senate replacement bill actually includes even more advantageous Medicaid expansion terms for States like North Carolina than the ACA had (appears to have 95% FMAP for long run instead of 90%).

If expanding insurance coverage is an important policy goal, there won’t be a more advantageous way for States to achieve that goal than a Medicaid expansion with favorable terms like those included in the ACA, or in the Republican health reform bill that seems to be picking up steam in the U.S. Senate. Much like the ACA, expect the Senate to set the terms for what can actually become law re health reform in Republican controlled Washington.

Fact checking Medicaid expansion

Will Doran, a News and Observer/Politifact reporter has given a Mostly True rating to Governor Cooper’s claim that North Carolina is already paying for Medicaid expansion.

I have long been a supporter of Medicaid expansion as anyone who has read much of what I have written will know. I have a piece coming out in the next issue of the North Carolina Medical Journal that tries to make the case for the expansion (I was written last Fall, with a light update). I consider the case for expansion to be fairly straightforward, but there are many complicated moving parts to get both the coverage and financial numbers straight, and certainly to estimate what I would call derivative effects like jobs.

Just to help identify some of the complexities, I include a copy of my correspondence with Will when he asked my advice on this Fact Check. He wrote me On Jan 11, and I answered later that night while riding in a cab in Washington DC, so its not the most beautiful prose but you get the point (I italicized and bolded my answers here for clarity & I removed Will’s email and phone number):


Some answers below.

From: Doran, Will
Sent: Wednesday, January 11, 2017 7:51 PM
To: Don Taylor
Subject: Media inquiry on Medicaid in North Carolina

Hi Professor Taylor, I’m a reporter for PolitiFact North Carolina and the News & Observer in Raleigh. I’m working on a fact-check about Medicaid and was hoping you could answer what’s probably a stupid question that I have.

North Carolina residents and business pay 2.4 percent of the taxes the U.S. government collects. Is it safe to also say that the state’s taxpayers cover about 2.4 percent of the federal government’s Medicaid expenses? Or is the math much more complicated in reality?

Math is more complex than this. It is possible this is a reasonable estimate, but I am not sure without some work and digging.

Here is a toe dip into the complexity. Social Security payroll taxes are a key source of federal taxes paid in, but they don’t go to Medicaid expansion, and another large tax are Medicare payroll taxes that don’t pay for Medicaid expansion. Medicaid (federal share) is generally funded from general tax revenue (income taxes) and there are a variety of taxes levied by the ACA that could be thought of as paying for the expansion. This post address expansion and taxes, but doesn’t really answer your question.

This link lists the ACA taxes

I also have one question that’s more policy-related, if I may take up a bit more of your time. Gov. Roy Cooper has said Medicaid expansion could create tens of thousands of jobs in North Carolina. But I know other states have not necessarily had that kind of result.

Kentucky, for example, has actually lost health care jobs since accepting the Medicaid expansion – despite a study that said the state would gain jobs. Is there any reason to believe that either scenario (the job gains or the job losses) is more likely to happen in North Carolina if we accept the expansion?

I am not sure. Surely someone must have done a summary of job impacts across states? Why did you pick Kentucky? There is a new model out focused on Michigan that predicts big job impacts….but I have read some criticisms of the study say the effect projected is implausibly large. The methodology of any given study in question is important. This is not really my area, but I will say from policy standpoint that I think job gains are what I would call derivative effects and not the primary intended effect. However, leveraging Billions of dollars into the state that wouldn’t otherwise be spent in the state will either increase jobs and/or wages paid to existing employees and/or expand revenue to health care providers that can be used for other purposes (like have a better bottom line). So, you could have derivative economic benefits even if you didn’t create more jobs. I don’t know this area better in part because I don’t think of jobs as the main point of Medicaid expansion. The key issue is how important is it to expand health insurance coverage? If it is impt, there will never be a more financially advantageous way for the state to do it.

I am sorry the answers are not simpler.


I appreciate any help you can give me about either of these questions. And if a phone call works better for you, my number is xxxxxxx.

Thank you.

Will Doran

PS here’s a news article on the Kentucky situation if you’re not already familiar:


Is there any space for a Medicaid deal in N.C.?

Yesterday, a federal judge issued a 14 day temporary restraining order against the federal government granting the Cooper Administration’s request for Medicaid expansion. I am unsure if there will be more federal judges or if this is the end of the Governor’s request, because 14 days is lots longer than the Obama Administration has left.

In the longer run, is there any space for a Medicaid deal between the Governor and the General Assembly? A few thoughts:

  • North Carolina’s pending Medicaid 1115 waiver will be taken up by the Trump Administration. I doubt a Clinton Administration would have granted it without an expansion of coverage, but who knows what the Trump administration will do on any topic. But, the executive branch implements changes to Medicaid and typically negotiates with CMS about such things. Governor Cooper has obviously shown policy initiative here whether you agree with what he did about expanding Medicaid, or not. And he has nominated a seasoned health policy professional with great experience running CMS as his own Secretary of HHS–you couldn’t ask for a more capable secretary to lead a negotiation with CMS and to roll out a reform. The General Assembly needs the Governor and his team to bring about the reforms they desire for Medicaid.
  • The Governor showed the policy priority that is coverage expansion for Democrats by stating his intent to expand Medicaid as he did, at some risk politically. That may be dead, but the winds of health reform that have blown nationally in the face of Dems politically for the past 6 years are getting ready to change 180 degrees (google loss aversion). There will almost certainly be some maintenance of extra federal monies to states for expanding coverage to low income persons (just look at the GOP Senators asking for this in States that have expanded), and if there is not a maintenance of the private insurance coverage gains that have come via the ACA, there are going to be 500,000 angry North Carolinian’s with subsidized coverage today who no longer have it. To expand coverage, the Governor will need to the General Assembly to finance North Carolina’s share of any such coverage expansion using federal money with presumably fewer strings attached than in the ACA 1.0.
  • I can think of one big idea that could improve the odds of a deal. First, assuming new flexibility for states in Health Reform 2.0, I would suggest the state saying we will work to expand coverage of low income persons and reforming the delivery system while giving the federal government the responsibility for financing Long Term Care in Medicaid, especially for the so-called dual eligibles who are covered by Medicare and Medicaid (much reading on this here). The dual eligibles are the most expensive part of Medicaid and their care wasn’t changed by the ACA, and the pending 1115 waiver doesn’t address dual eligibles. Off-loading financial responsibility for this group while taking more responsibility for low income persons in return for flexibility in how that is done is a trade that makes sense for N.C. because this effort can more directly help us move towards a stable safety net and individual insurance market to run along side our employer based insurance system.

The short, and obvious answer is that the Governor and the General Assembly need each other to achieve their goals. And the people of North Carolina need for them to figure this out. Perhaps the policy space needs to expand to work out a deal that makes sense for everyone.