Physicians and hospices are largely supportive of a CMS experiment that will allow Medicare beneficiaries to simultaneously continue treatment aimed at helping them get better while starting palliative care
to help them die as comfortably as possible. However, patient advocates say that, as the experiment is structured, program participants will be too sick to benefit from any curative treatment they may receive.
In a related development, payers are embracing a new Medicare Payment Advisory Commission
suggestion that Congress require Medicare Advantage carriers to cover hospice
stays for the first time.
The CMS demonstration project was outlined in the Patient Protection and Affordable Care Act. At present, Medicare beneficiaries are required to forgo curative services if they elect hospice care. However, recent studies have revealed that getting both forms of care concurrently improves quality of life and reduces costs since it will lead more people to elect hospice care instead of making frequent hospital visits at the end of their lives.
To explore the matter further, the CMS will pay a select group of hospices $400 per beneficiary each month for palliative services, while providers and suppliers of curative services participating in the program can still bill Medicare for their services. Hospice organizations must apply for the demonstration no later than June 19.
The demonstration program of concurrent curative and palliative care holds great promise, according to Dr. Amy Kelley, assistant professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai. Patients with serious illnesses and their families want the highest quality care, consistent with their own values and goals, and delivered in the community where they live, she said.
Should the experiment be a success, “this could lead to a benefit redesign for all Medicare beneficiaries,” Kelley said.
Last year, Kelley published a study that found hospice patients had significantly lower rates of hospital and intensive-care use, hospital readmissions and in-hospital death when compared to the matched patients who weren't in hospice.
The pilot program is “long overdue,” said Tim Bowen, president of Haven Hospice, a not-for-profit facility in Gainesville, Fla. “Our experience with concurrent care has led to a marked improvement in the access to, and quality of, patient care while the duration and utilization of aggressive therapies has declined.”
This demonstration could help change end-of-life care by increasing coordination of care between physicians and other curative providers and hospices, according to Theresa Forster, vice president for hospice policy and programs of the National Council on Medicaid Home Care, an advocacy group affiliated with the National Association for Home Care & Hospice.
“We would also expect that, through the demo, providers in other sectors will grow in their understanding of the principles on which the hospice benefit was founded, and this could play a role in expanding hospice's role in the healthcare continuum,” Forster said.
Patient advocates are not as positive about the demonstration. “I have some real concerns,” said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy, an organization that helps ensure seniors have access to coverage and treatment. “It would be a much more interesting and robust initiative” if it hadn't been limited to patients with six months or less to live, Berthelot said.
The demonstration's impact could be much greater if it were for people fighting life-threatening illnesses, but still not yet at the point of running out of care options. Had the program targeted this demographic, curative treatments might have a higher chance of being successful, she said.
Another downside is that it could further weaken the presence of not-for-profit hospices in the U.S., according to Dr. Brad Stuart, CEO of Advanced Care Innovation Strategies, a consulting firm that advises hospitals, health systems and payers on advanced-chronic-illness treatment practices.
He noted that $400 a month may be sufficient for a large for-profit hospice that has the staff and infrastructure to pick up a large number of new clients, but for small shops that amount per patient may not be enough to establish the staffing resources needed to offer an adequate experience.
“Small nonprofits will probably get eaten for lunch by the larger guys,” he said.
Regarding the MedPAC recommendation, plans are largely supporting a March 15 proposal in which it asks Congress to require Medicare Advantage
carriers to cover hospice stays. Since the program's inception in 1982, consumers have had to obtain separate Medicare fee-for-service coverage for hospice care.
The possible change would come as 14.4 million, or 28%, of Medicare beneficiaries are enrolled in private Medicare Advantage plans, up nearly 10% from 2012, according to the Kaiser Family Foundation. Since 2010, enrollment in Medicare Advantage plans has grown by 30%.
The number of Advantage's critically ill enrollees electing to get hospice coverage, meanwhile, has grown from 30% in 2000 to 49% in 2011, according to MedPAC.
“High quality, compassionate palliative and hospice care is an important source of support for people and families facing serious illness, and our members are increasingly asking for this valuable benefit,” said Sarah Bearce, a spokeswoman for UnitedHealthcare .
Carving the benefit in would “enhance coordination of care and reduce fragmentation of care, especially during the most vulnerable phase in the life of a member and their caregivers,” said Eve Gelb, senior vice president of healthcare services for SCAN Health Plan.
Other plans were not as supportive, and will likely oppose it should the CMS implement recent proposed cuts for Medicare Advantage in 2015.
“For seniors, these cuts will result in increased costs, reduced benefits and fewer coverage options,” said Graham Smith, senior director of business development and federal programs at HealthPlus of Michigan. “With that in mind, it will be essential for CMS to ensure adequate funding to Medicare Advantage plans to provide the hospice benefit and ensure beneficiaries don't suffer a loss of end-of-life care, support and services.”Follow Virgil Dickson on Twitter: @MHvdickson