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.

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.