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.

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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.

Care Planning Act of 2013

Senators Mark Warner (D-VA) and Johnny Isackson (R-GA) have introduced the Care Planning Act of 2013, which among other things expands funding by Medicare and Medicaid for “patient centered care planning” for people with serious illness. The recently introduced Hospice Help Act of 2013 is also bipartisan in nature.

The addition of funding for such discussions and modernization of the hospice benefit was a bipartisan notion before our country hit maximum full stupid 4 Augusts ago when such a provision in the ACA became death panels, pulling the plug on granny when members of Congress went home for recess. From an evidence based policy perspective, we are still trying to recover, and these bills are a start.

Le me give you a hint: granny is going to die, as are you and I,it is only a matter of when and from what.The provisions in these two bills simply help provide more evidence based options to people facing this reality. And around 8 in 10 people who die annually in the U.S. are Medicare beneficiaries, so Medicare is where the action will be on this sort of thing.

The tag hospice will get you dozens of posts on related issues.

This Health Affairs post of mine back in May, 2013 places the issues of end-of-life/hospice in the overall context of Medicare policy.

Hospice HELP Act of 2013

Some quick thoughts on the “Hospice Evaluation and Legitimate Payment Act of 2013” the so-called HELP hospice Act (h/t for the text to @HospiceAction).

  • It is co-sponsored by a Democratic Senator (Ron Wyden of Oregon), and a Republican (Pat Roberts of Kansas). Until the unhinged and fact free death panel rants of August 2009 and continuing, the hospice movement enjoyed bipartisan support, I think because everyone eventually dies and it is in everyone’s self interest to improve the options of those who are acutely facing death. That bipartisanship has been on hiatus since the passage of the ACA. For example, the word palliative care does not appear in the ACO regulations, and the word hospice appears only once. However, these are both crucial in any attempt to deliver care to a defined population of elders with the goal of increasing quality of life/value of care while addressing costs. If the HELP hospice Act goes forward, it will show we have been able to get back to some policy in this general area.
  • The bill proposes a modification of the face-to-face encounter re-certification provisions in hospice when a patient uses hospice beyond the first 60 day eligibility period. The big picture is worries about increasingly long stays among long stayers as outlined by MEDPAC. The goal is to right-size the regulation and not make it too burdensome, while making sure use is appropriate.
  • Proposes a hospice payment demonstration to replace the 30 year old per diem payment approach.  This would delay the Secretary of HHS’s ability to bring about a new hospice payment system (which cannot be done before October 1, 2013 under the auspices of the ACA), but with the HELP hospice bill it could not be done until October 1, 2017, after the proposed demonstration. Most of the bill details how this demonstration should be done (include at least 15 representative hospice providers, have an evaluation and report, the 2 year demonstration must be budget neutral). Note, this is not the same 15 hospice demonstration that was enabled by the ACA for testing concurrent care, but that has not been funded. However, I read the language of the HELP hospice Act to be broad enough to encompass this concurrent idea.
  • Sets up a regular survey requirement for hospice providers by a local of State accreditation agency once every 36 months.

Hospice policy questions used to be dealt with in a bipartisan fashion. It will be interesting to see if we have gotten back to the point at which we can have any health policy legislation move ahead in its own right, and not simply become the next volley in the ongoing meta health policy wars. The hospice tag of this blog will get you much more info on this area if you want it.

New paper confirms hospice reduces Medicare costs

A new paper in Health Affairs by Amy Kelley and colleagues shows that hospice reduces Medicare costs as compared to what they would have been had hospice not been chosen by the patient over a variety of common lengths of use in the Medicare program.

The paper is in many ways a replication of the 2007 study (funded by the HCFO initiative of RWJ) that I did with colleagues at Duke that found mean savings after the point of hospice election of just over $2,300, and that the savings (hospice costs after election as compared to normal care) were maximized with a length of hospice use of between several weeks and a few months.

Kelley et al.’s paper goes beyond ours in that it controlled for functional status of persons in hospice measured at a finer level than could the work that we had done. This lead to reasonable wonders about the impact of potentially important omitted variables in our work. The work of Kelley and colleagues has confirmed and extended our general finding that hospice saves Medicare money after accounting for the fact that patients choose hospice–and therefore are systematically different from those who do not. They identify larger savings very near death than did we. It should be noted that in addition to controlling for functional status variables that were omitted in our work, the current paper also is done on more recent data years (2002-08; our paper went back into the 1990s-2005). For example, they find hospice reduced Medicare costs by $2,650 for hospice stays of 1-7 days; $5,040 for those lasting 8-14; and $6,430 for stays of 15-30 days. Given that the median length of hospice use is around 18 days in the Medicare program, over the most typical range of use, hospice should be encouraged, and policies to increase use identified. The ‘short stay’ problems should not be forgotten while trying to address problems related to very long stays.

I know of nothing else that improves quality of life of patients and routinely reduces costs that is paid for by Medicare.

A word on data. The Health and Retirement Survey (HRS) is a massive, long term data effort funded by NIH for the past 20 years. HRS enrolled panels of patients and followed them over time. Amy’s paper took advantage of the joining of self-reported data on function collected in such surveys, to Medicare claims data that documents use and cost paid by the Medicare program. Such collection and linkage and time consuming, expensive and hard. Without the foresight of NIH to invest in data, this paper would not exist. A hole remains in the hospice literature because Medicare Advantage plans do not have to make claims data available as a matter of course. This makes no sense for a nation trying to address cost, coverage and quality issues in health care. update: when Med Advantage patient elects hospice they revert to Part A. The difficulty of claims from Medicare Advantage is a general problem.

If you enter the search term hospice into the blog sidebar, you get many posts on hospice policy if you want to read more.

Note: paper is gated; working on a clean link.

Amy S. Kelley, Partha Dah, Qingling Du, Melissa D. Aldridge Carlson, R. Sean Morrisson. Hospice Enrollment Saves Money for Medicare and Improves Quality Across A Number of Different Lengths-of-Stay. Health Afffairs 2013;552-61.

Hospice and functional decline

An interesting new paper in the Journal of the American Geriatrics Society (JAGS) on different patterns of functional decline (ability to walk, eat, cognition) among persons who were in hospice care and ultimately died. The most important point of the paper is that there is great heterogeneity in ability to function, even on the last day of life.

In an inverse probability–weighted sample of individuals who had a PPS score recorded in the last day of life (n = 1,959, 22.6%), 35.9% had a PPS score of at least 40, indicating some oral intake, variable mental status, limited self-care, and an ability to get out of bed for at least part of the day. [my note: PPS in this context is a standard functional status measure often used in hospice and palliative care settings; 10 is quite poor, 90 is very good]

Two points on hospice policy here, both related to MEDPACs great interest in (shortening) long stay hospice users. First, over one-third of patients in this sample had reasonable functioning on the day they died. This shows the difficulty of predicting death with any precision, even among the subset of patients enrolled in hospice (all patients in this study died, so this is not an issue of discharging alive from hospice). Second, table 2 from this study demonstrates the current reality of hospice as not simply being used to treat Cancer; a broader set of conditions including dementia and debility(or frailty) are also included.  Such conditions tend to have a less clear disease course than does Cancer. Both the difficulty of predicting death, and the spread of hospice into non Cancer diagnoses (which has been a stated goal of Medicare hospice policy), have likely contributed to the  increase in relatively long hospice stays that have drawn so much policy attention. More work to demonstrate the link between functional status and length of hospice use/patterns is likely to be an important part of any Medicare hospice payment reform.

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Pamela Harris, Esther Wong, Sue Farrington et al. Patterns of Functional Decline in Hospice: What Can Individuals and Their Families Expect. Journal of the American Geriatrics Society 2013 online first.