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.

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.