January 1, 2016: Huge Day for Medicare End of Life Policy Changes

January 1, 2016 will be a huge day of changes for Medicare end of life policy. As noted earlier, Medicare will begin paying for advanced care planning and will begin a concurrent hospice care demonstration on New Year’s Day. We now know that on the same day the program will institute the most consequential change in Medicare hospice payment policy since the beginning of the benefit in 1982:

• Medicare will move from a straight per diem base payment for hospice, to a two-tiered base payment of $187.54/day for the first 60 days in hospice, with a lower payment of $145.15 for subsequent days (column 6 below from August 6, 2015 Federal Register).

Section 1814(i)(6)(D)(ii) of the ACA required the Secretary of HHS to consider a new payment methodology for hospice, and the primary discussion by MEDPAC and others had been the development of a so-called “U shaped” payment approach that better matched the differential intensity of care across different links of hospice use. The primary goal of the payment changes seems to be better alignment of the payment methodology with the actual resource use of hospice providers, with tremendous interest in reducing very long hospice stays that many view as fraudulent, or at least not in keeping with the best use of hospice. However, very short hospice stays are also a problem.

The actual payment change is simpler than a U shape payment would have been (higher in the first few days and the last few days and lower in the middle) approach suggested by MEDPAC, though they have publicly supported the change as a first step.

My guess is that it won’t be 3 decades before the next hospice payment approach change is announced by Medicare, and that we are likely entering a period when change is relatively common. I hope we are also going to be clear about policy goals, and collecting data to inform evaluations of same.

Medicare will pay docs to discuss dying

Medicare announced today that it will pay physicians to discuss dying, and the preferences, choices and options that patients have when they face the inevitable (it is only a matter of when, and from what). Six Augusts ago, the summer congressional recess exploded into “death panels” as a way to argue against the ACA. The offending provision would have simply paid physicians to have this type of planning discussion. Five Augusts ago, a RCT of early palliative care showed that patients with stage-4 lung cancer who essentially had such “goals of care” discussions–but who could subsequently choose whatever care options they wanted–actually lived longer, had better quality of life and cost a little less as compared to those who did not have such a discussion.

The idea that Medicare wouldn’t pay for a discussion of preferences and options for patients is absurd since over 8 in 10 persons who died last year in the U.S. were insured by the program. Medicare is inherently in the dying business, and each of us will do it once. The policy announced today will allow physicians to get paid to have goals of care discussions with patients and family members (see p 246), which is important to help patients to make the most informed choice possible. This policy represents a small step toward sanity in this area.

We at Duke have a Center for Medicare and Medicaid Innovation Award on palliative care with Four Seasons, which is seeking more to develop more comprehensive payment changes to how the Medicare program pays for end of life care, but we are still early days in the project (CMMI billboard May 16).

Statin Discontinuation

The Palliative Care Research Cooperative‘s RCT of statin discontinuation came out in JAMA Internal Medicine yesterday. The patient population had a variety of terminal illnesses with an expected life span of greater than 1, but less than 12 months. Highlights of findings:

• No survival difference
• Quality of life was better on some measures, and no different on others
• Modest cost savings were realized by stopping a statin ($3.37/day; mean savings observed in trial $716)

The main story is that stopping statins in terminally ill patients can be done safely, and that doing so makes the lives of very ill people a little better, while costing a little less. Imagine how rich we would be if the RCT reported had been of a new drug that produced the same results. People would be desperate to take it!

The study was a bit different than most RCTs because it was not double blind (all persons consented to being randomized to stopping or continuing their statin; those that were in the ‘stopped’ arm knew that they had stopped taking the medicine). This was important because a key worry was whether stopping a statin would lead to a loss of hope, or other negative psychological outcomes for patients. We did not find this to be the case, but it is an important question with respect to patient well being that could not be answered via a double blind RCT. Several top medical journals wouldn’t even review the manuscript because of this issue. I would never say a journal “has to”publish a given paper, but not reviewing this paper for that reason shows they don’t get palliative care, and the very important intervention of knowing when to stop doing something.

Cost v value as policy focus

Ezra Klein has a nice post running over the political and policy problems of focusing on “cost reduction” in health care, and instead suggest focusing on the receipt of value for the dollars spent. He frames the decision in partisan terms–what should the guiding health policy be for the Ds as opposed to the Rs, but there are some limitations to a cost focused strategy in policy terms, even if you believe the health system is unsustainable.

Two questions are paramount here. The first is what is the appropriate out of pocket exposure that an individual should face prior to receiving care? Does it differ by age? Income? Health Status? You tell me….The problem with blunt tools like large deductibles is that they likely reduce good and bad spending (high value and low or no value). The roll out of the ACA has helped to crystallize this question, if only we could get to the policy and off of the macro political narrative.

The second question (how to get to higher value for the dollars spent?) is laid out in some of our recent work at Duke looking at the preferences of Medicare beneficiaries who have cancer. Simply put, could expanded patient and family choice in they types of care covered  by the program (that pays for the care of 8 in 10 persons who die each year) lead to a more productive expenditure of resources? And in doing so, possibly reach what sounds too good to be true–lower spending with higher benefit to patients? We are about 3 months into enrolling patients into a Center for Medicare and Medicaid Innovation Center grant (CMMI) to demonstrate, evaluate and propose potential payment changes for how Medicare reimburses palliative care. This feels like it might be the most important work I might do in my professional career. If you change the incentives in how Medicare pays for end of life care, it will filter down into the rest of the health care system.

I am at the American Academy of Hospice and Palliative Medicine Annual Assembly (follow #HPM15) in Philly for the next two days, and many parts of the questions and answers under the “value proposition” will be on display here. We as a field (hospice and palliative care) need to do a better job of translating the research evidence base into usable information for policy makers. I think the country is ready to listen, with IOM report Dying in America helping in this manner. When will the political system be ready for the next steps in health policy? (and the next, and the next?, etc)). Not sure, but we need to be ready to lead into the most difficult health policy questions when they are, and the biggest goal–focusing on maximizing value for the health care dollars we spend.

PCRC semi-annual meeting

I am in Chicago for the semi-annual Palliative Care Research Cooperative (PCRC) annual meeting. This is a great meeting–one of the most intellectually stimulating meetings that I attend.

The National Institute of Nursing Research (NINR) has funded the PCRC, which is at its heart a cooperative group for research projects (think Cancer cooperative group except that the RCTs are of palliative interventions as opposed to investigational drugs). A big focus on this weeks meeting is around caregiver research. We at Duke submitted an RO1 last week to expand the study reported here nationally, using the patient recruitment sites in the PCRC.

The impact of caregiving is easily the most important public policy question of our time that receives very little public discussion. Papers like this one and the work of the PCRC will hopefully change this.

More on hospice concurrent care

I spent a lot of last week in Washington DC, first at the Hospice Action Network event Tuesday on length of hospice use, and then being a part of the Friday research plenary at the National Hospice and Palliative Care Organization’s (NHPCO) Management and Leadership conference. There was a great deal of discussion of the recently announced CMMI Concurrent Hospice Demonstration program, and it is striking how little understanding there is in the field of exactly what the demonstration entails. A few quick thoughts:

• My understanding of the program as a essentially a test of the “Temel study” in which the $400/month would fund goals of care discussions and some phone monitoring, with hospices then able to bill the hospice per diem if they provided more care is wrong. The language about billing other parts of Medicare under Parts A, B and D seems to refer to, for example, the ability of a hospice to provide social worker care that could be billed separately to Part B. However, it is quite complicated to determine when that is allowable as a one-off, and many hospices are not set up to do this in the first place.
• One key issue in all this is inducement. We have generally spent lots of time worrying about providers inducing patients to receive further services provided by the same providers, but the goal of concurrent hospice seems to actually be inducement at some level (to get people to elect hospice who ohterwise would not have). Some new thinking on this general issue is needed with respect to hospice and palliative care.
• If it really is the case that you get $400/month and essentially are responsible for the entirety of the hospice benefit, then I don’t think anyone will apply for the demonstration.
• At the NHPCO meeting on Friday, an official from CMMI came and talked generally about the demonstration and the hospice benefit and industry. I heard him say fairly clearly that CMMI was open to more discussions about the shape of the concurrent care demonstration should take. Others seem to have heard differently. Some more refinement and discussion is needed.
• Keep in mind that patients have to be eligible for hospice to qualify for the demo, which means they can be certified as having less than 6 months of life. They are eligible to elect hospice at that point, but they have not chosen to do so. It is a good idea for CMMI to try out a new approach that allows for concurrent care for this group of patients to see if you can: (1) improve their quality of life; and (2) potentially increase their likelihood of electing hospice; and (3) potentially reduce costs even in the subset of patients who will not elect hospice. I know many are critical of the focus on hospice-eligible patients only because they believe concurrent hospice/palliative care should be pushed further up the disease course. I agree with them generally, however, but focusing a small intervention on patients who are hospice eligible but who have not elected it seems a reasonable place to start, if a plausible demo can be constructed.
• A key issue is what is it that participating hospice providers will be promising to patients, family members and the rest of the health care system for $400/month?
• Two options to push the conversation: First, hospice providers could describe what they could do for $400/month, and propose that to CMMI. Say clearly, here is what we could do for that. Is that what you want to try? And make clear that the constraint is what can be promised to patients, caregivers and the system. Second, propose a concurrent hospice model(s) for hospice-eligible patients, along with the financial resoruces that it would take to undertake a proposed demo. Simply say, we would love to try this; will you let us?
• I believe that a test of the Temel “early palliative” model that begins with a goals of care discussion, and proceeds with monitoring and information sharing, and integration of the hospice team into big decisions could be a fruitful approach, that is not risky in terms of the amount of money risked. The key is getting a realistic reimbursement level for the delivery of hospice/palliative services. There may be other models to test as well.

I give CMMI credit for rolling out this demonstration. However, I think it really needs to be the beginning of a more detailed discussion to identify the exact nature of what demos will actually be tried, and not the last word on the demo.

Is the SGR so dumb it warrants a gimmick ‘pay for’?

The only thing dumber than the annual SGR/doc fix charade where we lament huge Medicare Part B cuts that we know won’t happen is the debt limit. While I generally favor following paygo, I think the SGR is dumb enough to warrant getting rid of with a gimmick such as counting war savings draw downs.

Lets just start over.

Loren Adler has been consistently saying no, we need to pay for the SGR fix. I respect the position and generally am with him on such matters. However, he has gone even further and said that what I have now termed the second-dumbest thing in Washington (whatever the second dumbest thing is must be pretty dumb) has lead to fiscal restraint in federal health spending, because most of the pay-fors to push out the SGR cuts have come from health care spending. Even further, Loren implies that maybe only the dumbness of the SGR (huge cuts that are politically impossible) has enabled the other changes. If this is true, I just want to take a long nap.

In any event, I asked Loren for an analysis of the degree to which the changes to pay for pushing off the huge cuts that will never happen have been reasonable policy and he said he is working on such a post. I will link it when up.

One worry that I have is that any longer run SGR fix could bring about hospice payment changes that are scored as cost savings because they don’t project a change in behavior, but that might actually change hospice behavior in a manner that actually increases Medicare costs (reduce use in the cost saving range of hospice length of use). I was talking about worries around unintended consequences at yesterday’s Hospice Action Network event on hospice length of stay (I will link the vid when up).[here are my slides PPT_Deck_RCRT_dt3.20.14_shorter]

The difficulty in projecting what might happen to hospice length of use if we adopted a U Shape payment modification of the straight per diem, or perhaps a rebasing a la Home Health from a few years back is that there is no good evidence on changes in use after hospice payment changes. This is because Medicare insures over 8 in 10 decedents each year, and has had a straight per diem payment approach for the entire time. Further, since the hospice benefit is carved out of Medicare Advantage, there is not even proprietary evidence about different payment approaches and hospice. I can find no published study that shows any evaluation of a payment change in hospice in private insurance or in another country. If you know of one let me know.

I think the Medicare hospice benefit needs to be updated. I am worried about unintended consequences, in large part because there is not even clarity about the goals of hospice payment policy change. It needs to be gotten right. I am worried that hospice will get sucked up into a long term SGR pay for, and that the payment change will have behavioral impacts that we have no way to estimate.

Please note, Loren Adler is an excellent analyst. I am not saying he is dumb. His argument makes me reconsider my views of SGR, but as of yet I remain unconvinced.

Focus on Hospice length of use

I will be participating in a panel on Tuesday, March 25, 2014, 9:00-11:30am “The Right Care at the Right Time: An Open Conversation about Hospice Length of Stay” hosted by the Hospice Action Network, the advocacy arm of the National Hospice and Palliative Care Organization (NHPCO). The event will be held at the Columbus Club at Union Station in Washington D.C., but you can also watch via livestream.

Discussion on length of stay in hospice has largely been focused on worries about long periods of use (particularly those over 180 days)–that they may represent fraudulent or inappropriate care. Fraud is obviously a bad thing, but at least some of the long stays may essentially be the hospice benefit morphing into a back door long term care benefit of sorts. This is clearly not what is intended by the benefit, but such needs for patients and families are important, and the lack of a coherent long term care financing system in the U.S. is spilling over into Medicare policy in many places (hospice, readmissions, etc.).

Short stays in hospice represent potential quality problems, and the 25th percentile length of use has been ~5 days for a decade. Spells of use this short prior to death do not allow patients to reap the full benefits from hospice, but the call to increase length of use certainly has a normative tone; the persistence of such short lengths of use may also simply show the preferences of a subset of patients and families.

At the meeting I will present some preliminary work confirming that hospice saves Medicare ~$2,400 per patient after the point of initiation (in North Carolina, for 2009-10 deaths), as compared to matched controls for the same number of days of care/cost prior to death (this link is to many posts on hospice). These findings include the long stays, just as did my past work. Of course if you could get rid of long/inappropriate utilization, you would expand the cost saving potential of hospice. However, the behavioral response of any new change is unknown, and difficult to estimate a priori. The potential for unintended consequences abound, but there is a strong sense (that I share) that the hospice benefit in the Medicare program is in need of updating. Perhaps the most important question is this: What is(are) the goal(s) of hospice payment policy change(s)?

IOM Cancer Report

The Institute of Medicine this week released “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.” [full report; briefing slides]

The report lays out the cancer care continuum in this way.

Two of the reasons the IOM describes cancer care as being “in crisis” is the degree to which they say that the current system is not patient centered and evidence based. When searching for value in cancer care or health care generally, you are really asking whether a given course of treatment improves quality of life, extends life and how much it costs. If you can answer these three questions, then you have a chance of asking (and maybe answering) the question of “is this worth it?” The “is it worth it?” question is relevant at both an individual, but also at a system and payer level (for Medicare in particular, given that 8 in 10 decedents in the U.S. are insured by Medicare and the fact that cancer disproportionately affects older persons, which is a bit of a tautology since it is the second leading cause of death in the U.S.).

The key in trying to join “patient centeredness” with the “evidence base” at the patient level are the items in the purple box (care planning, palliative care, imagining and responding to sequelae of symptoms and burden to patients and caregivers, etc). This is one place those three questions should be asked, discussed and answered over and over, since this is where the choices that patients have in treating cancer (say if covered by Medicare) get banged out into an actual treatment trajectory.

The choices that are offered to patients are also important, and Medicare has the legal/regulatory authority to make coverage decisions and truncate choices, but of course this is politically very difficult.

Our team here at Duke will hopefully be publishing the results of a study we have just completed in which patients with cancer and their caregivers identify what treatment options are most important if a serious resource constraint were imposed in Medicare, as it provides some insight, both into how conversations that are inherent in the purple arrow above can be structured, as well as how policy at the Medicare-level might be altered.

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.