July 22, 2015 1 Comment
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.