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.

IOM report “Dying in America”

The Institute of Medicine yesterday released its report “Dying in America: Honoring Individual Preferences Near the End of Life.” It is a 500 page report with lots of interesting and relevant information, and it suggests many avenues for improvement. One key theme that comes through is the call for a focus on individual preferences near the end of life. The study that we recently published in the Journal of Clinical Oncology is directly relevant to this conversation.

This report is plainly, and comprehensively written, and I think its publication signals the end of our long, national stupid that began when a proposal in the ACA to pay for advanced care planning was termed “death panels.”

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.


Project Title: “Increasing patient and system value with community based palliative care”
Geographic Reach: North Carolina
Estimated Funding Amount: $9,596,123


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.

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.

Concurrent Hospice Demonstration Announced

Yesterday, CMS announced a concurrent hospice demonstration that will begin this Summer in the Medicare program. 30 hospices will be allowed to begin the 3 year pilot, and must apply by summer 2014 to do so. The so-called Medicare Care Choices Model will allow hospices to provide care to Medicare beneficiaries without their having to “unelect” curative care first (they must do so now under the hospice benefit).

I haven’t been able to invest lots of time investigating this yet, but I am unsure if this is the Hospice payment demonstration enabled by Section 3140 of the ACA.  This FAQ sheet says it is enabled under Section 1115a of the Social Security Act (though it is possible that Sec 3140 of ACA amended 1115a; don’t have time to dig it out). And I think the ACA demonstration was a far broader demonstration for new payment models for hospice more comprehensively, and talked of 15 instead of 30 hospices.

The demonstration will allow hospice providers to receive $400/month to interact with and monitor patients. Other providers will continue to bill Parts A (hospital), B (doc) and D (pharma). I must say that my first thought was $400/month is not very much, so I actually don’t get how this will be the case:

Hospices that apply and are selected to participate in Medicare Care Choices Model will provide services available under the Medicare hospice benefit for routine home care and inpatient respite levels of care that cannot be separately billed under Medicare Parts A, B, and D. These services must be available 24/7, 365 calendar days per year. CMS will pay a $400 per beneficiary per month fee to the Medicare Care Choices Model participating hospices for these services.

As $400/month is less than 3 days of the general hospice per diem, I believe this is essentially allowing patients to have a comprehensive goals of care/family discussion for seriously ill patients who are not ready to elect hospice as their primary provider of care. If they later do choose hospice, will they then still have to unelect curative services as with current hospice policy, and the hospice would then bill Medicare for the normal hospice benefit? Or does the language of “not otherwise available in Parts A, B and D mean that hospices get $400/month to get involved, and then simply bill the hospice benefit concurrently for actual care provided using the hospice per diem? It must be the latter, but I think some further clarity is needed.

I see this amount of money ($400/month) as basically a test of whether exposure to early hospice care can yield the positive outcomes found by Temel et al. 2010 with stage 4 lung cancer. However, the snippet above sounds like hospices are on the hook for all hospice care 24/7, so it must mean that they can bill hospice concurrently above and beyond the $400/month. The patient population is restricted to those with advanced cancer, COPD, CHF, and HIV/AIDS. They have basically excluded dementia, debility and failure to thrive, the diagnoses associated with longer lengths of hospice use, which actually makes sense to me.

I am a big fan of concurrent hospice/palliative care and think it is the direction we should move. However, I don’t fully understand the economics/rules of what care is actually going to be provided at this point and need to dig further.

update: AAHPM says this is the demo authorized by sec 3140 of ACA.

On the road, talking about hospice and palliative care

I am on my way to the LA area to present some preliminary research on the cost saving potential of hospice and palliative care, and reform of the Medicare hospice benefit, at City of Hope Hospital in Pasadena. There, I will be meeting with Dawn Gross, Chair, Department of Supportive Care and Palliative Medicine and others at City of Hope to discuss some some work we are doing on barriers to hospice for persons with blood borne cancers, and to kick around some future research collaborations between Duke and City of Hope. On Wednesday, I will head down to San Diego for the Annual Assembly of the American Academy of Hospice and Palliative Medicine. If you will be there and want to chat, say hi on twitter @donaldhtaylorjr on drop me an email.

WaPo story on the Medicare hospice benefit

WaPo has a story today with a nearly irresistible click bait  headline “Hospice firms draining billions from Medicare.” Like much health policy that focuses on the end-of-life, the story raises some valid points, but gives in to the sensational and turns away from the far more difficult reality of the counterfactual: current hospice policy as compared to what?

Medicare policy is inextricably end-of-life policy due to the fact that more than 80% of the people who die each year in the United States are insured by the Medicare program. That is because Medicare insures virtually all persons age 65 and older, and everyone eventually dies.What care should the elderly receive? Does care increase life span? Does it improve quality of life? How much does it cost? Who should decide if the intersection of these questions are worth it? These are very difficult questions to answer. Our country cannot even bare to ask them. So, we look for examples of malfeasance being the problem, in large part because as long as we focus there we don’t have to stare at that set of questions above and imagine our mother, wife, brother or ourselves being the one about whom the questions are posed.

I very much agree with the WaPo story that Medicare covering hospice in 1982 transformed a renegade movement into a big business. However, recent work has demonstrated that hospice reduces Medicare costs as compared to what they would have been under normal care, and that is including the tail of long-stay, high hospice expenditure patients. That does not mean that inappropriate utilization of hospice should be tolerated, but demonstrates that most of the policy focus is on long stay hospice, ignoring the short stay issues. To wit, in the WaPo story:

The average length of a stay in hospice care also jumped substantially over that time [Don’s insert: 2000-2012], in California and nationally, according to the analysis.

This is true, but incomplete. From the 2013 MEDPAC chapter on hospice (p. 261-62):

In 2011, 45.2 percent of Medicare beneficiaries who died that year used hospice, up from 44.0 percent in 2010 and 22.9 percent in 2000. Average length of stay among decedents, which grew between 2000 and 2010 from 54 days to 86 days, held steady at 86 days in 2011. The median length of stay during the same years remained stable at approximately 17 or 18 days.

Mean length of stay has risen, while the median has stayed about the same. Half of the Medicare beneficiaries using hospice do so for less than 3 weeks, and the 25th percentile stay (the period of time that 1 in 4 Medicare hospice users use the benefit) has been around 5 days for 15 years (see page 271-72).

Long hospice stays pose policy problems, but so to do short ones. Those using hospice for what amounts to a long weekend prior to death mean that patients are not receiving the full benefits they might from hospice, as well as foregone cost savings that Medicare could have realized has hospice been elected earlier. So while some patients need to use hospice less, far more likely would benefit from using it longer before death, yet this side of the hospice equation is not even mentioned in the WaPo story. And in fairness to the WaPo reporters, MEDPAC has focused on the long stay issue the past few years as well.

A part of this story that is easy to miss is that the lack of a coherent Long Term Care (LTC) system in the U.S. puts pressure on Medicare benefits like hospice and home health. As MEDPAC notes, the most rapidly increasing length of stays under hospice are for non-Cancer diagnoses like Dementia (under Neurology in table below).

ScreenHunter_02 Dec. 27 11.58

For a subset of patients, the hospice benefit may essentially be morphing into a backdoor LTC benefit, with the incentives of some hospices aligning with those of family members desperate to provide a home based care solution for a loved one with a serious illness that may not be terminal per the hospice benefit’s definition. This is a sign that the Medicare benefit package does not meet the needs of some of its beneficiaries. We at Duke have recently completed some work asking seriously ill patients what Medicare benefits would be most important to them if they couldn’t have everything; I am desperate to blog about the findings, but must wait until we get the main paper accepted by a medical journal, hopefully early in 2014. However, the persons most directly affected (patients) are ready for this conversation.

There are plenty of signs that the Medicare hospice benefit needs to be updated and modernized, preferably toward a concurrent care model. Long lengths of stay are just one. And the bright lights should not only be shone on hospice in the search for wasteful spending. As I wrote in Health Affairs blog back in May, 2013:

But all of the therapies available to chronically ill Medicare beneficiaries with life limiting illnesses should be subjected to similar scrutiny, not just hospice. Does it extend life? Does it improve quality of life? How much does it cost? Is it worth it?

The problem is not that some question the value of hospice under certain circumstances in which it is currently being used in the Medicare program. The problem is that hospice appears to be the only part of the Medicare benefit subjected to such scrutiny.

Saving money while improving quality of life

I have a post in the Health Affairs Blog titled “Saving Money While Providing Benefit in Medicare: A Standard Applied Only to Hospice.” Go and read it.

Here is a tag to many posts I have written on similar hospice policy themes if you want more.