RCT of Palliative Care in Heart Failure

A big team from Duke lead by Joseph Rogers has a new Paper (PAL HF) reporting the results of a RCT of palliative care in late stage Congestive Heart Failure, published today in the Journal of the American College of Cardiology. Patients who got palliative care had better quality of life, higher function and reduced anxiety and depression (with no survival difference, as hypothesized). Costs were not a primary endpoint, but will be analyzed in later work.

CHF_7-11-2017 8-56-05 AM.

After the publication of a RCT of early palliative care in stage 4 lung cancer in the NEJM in August 2010 showed improved quality of life, lower costs and longer survival, there was a move to see if such findings could be replicated in other diseases. This NHLBI funded study is part of that effort.

Real world evidence is provided imperfectly, especially with respect to policy. One example from this paper. This studies’ exclusion criteria ruled out patients with anticipated heart transplant or LVAD implantation within 6 months. Arguably, these patients aren’t ready for palliative care because they are seeking such aggressive treatments, but from a policy perspective, it is arguable that they definitely need the goals of care type of discussions that are a key part of palliative care. The successful conclusion of a trial of CHF without patients on the way to heart transplant or LVAD implantation leaves an evidence hole, even as we add to the evidence base.

Should patients thinking about an LVAD or a heart transplant get palliative care? I think the answer is yes, but this trial provides no direct evidence to inform this question. So, there remains an evidence gap (as always–good studies suggest more questions than they answer). However, the health care system often doesn’t and can’t wait for such answers, and in the case of palliative care there has been a tremendous increase in its provision at Duke, and across the nation since this study was began. The process and timing of research is slow, and the answers are often muddled, while the pace of change in addressing the needs of seriously ill patients is much more rapid. When one’s interest is policy applications, even an RCT–the gold standard of research–cannot answer all of the most pressing questions.

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

Death with Dignity Forum, March 17

I am participating Thursday, March 17 in a public forum discussing pending “Death with Dignity” legislation in the North Carolina General Assembly (Thursday, March 17, 4-7pm, Friday Center in Chapel Hill; free but registration required).

I don’t consider myself an expert on the topic of Assisted Death* (where the patient must administer a lethal dose of prescribed medications; that is the topic of the forum Thursday, and is the basis of the Oregon law) or Euthanasia (where a physician administers a lethal dose of medication; illegal in all U.S. states, but legal in some European countries), but do focus most of my research attention of hospice, palliative care and how we care for persons with disability. I am a member of the “Death with Dignity” panel to discuss how we care for the dying generally in the U.S.

I am ambivalent about Assisted Death legislation–meaning I have conflicted views and can see the issue from both the pro and con positions. I suspect most other panelists have quite strong views, either for or against. This got me to thinking about the most convincing case I have read about the pro and con positions as someone who remains ambivalent.

There is not a singular “pro” piece I can point to, but instead it is the fear of a future unremitting suffering for myself and my family (this worries me most–that I will burden my children) merged with my current position in life that leads me to see the “pro” point of view. By current position in life, I mean that I am a person with prestigious job and career status, power, good economic means and someone who is generally used to things going roughly speaking how I wish them to go. And if they aren’t going as I wish, I have a general sense that I can do something to change the course of events. The “pro” position of maintaining my options is quite intuitive to me.

This from Katherine Sleeman, a Palliative Care physician in England from the Cicely Saunders Institute, University College London is the most convincing, succinct argument against Assisted Dying laws that I have read. I won’t summarize it–it is short, so go and read it. The piece is effective and convincing in arguing against Assisted Dying legislation to me because it doesn’t treat the issue as a simple one, and also because it notes how much work there is to do to improve our systems of caring for sick and infirm citizens regardless of how this issue is decided.

In that sense, the issue of Assisted Dying is far from the most important end-of-life topic of our day, and the noise around this debate crowds out the most important issue as I see it–developing coherent systems of providing the care that most of us will need before we die. The basic policy milieu available to the dying and their families will effect far more persons than any Assisted Dying law ever would. Let’s not forget that.

 

*A fight of the language of how to even talk about this is possible, but not so useful. I think Assisted Death is the most descriptive term. The law being proposed is called “Death with Dignity” which is a more positive framing, and opponents will sometimes call this anything from killing to murder, which is obviously a less positive framing. My two cents.

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.

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.

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.