CMS to test concurrent hospice and curative care coverage

Terminally ill patients regularly call Dr. Christina Puchalski hours or days after tough conversations about the lack of remaining treatment options for fighting their diseases.

“Some people want to continue with curative treatment until it's really obvious it's not working,” said Puchalski, a palliative-care specialist and director of the George Washington University Institute for Spirituality and Health. “Some say, 'I really need to try it all.' ”

Up to now, that desire to continue seeking a cure has forced patients and their families to go without Medicare-paid hospice care. Medicare policy has been that the program won't pay for hospice—which includes pain management, nursing care, counseling, and respite care in a hospice facility or at home—until patients stop treatment to slow or cure their disease, such as chemotherapy or radiation therapy.

For patients, the “dance” of hearing the news that they have a terminal disease and accepting it starts with the diagnosis and often continues until the Medicare coverage policy forces the issue. “If you're talking about hospice, the dance has to end,” Puchalski said. “The patient has a very hard choice.”

Now that one-or-the-other policy, which has been criticized for not recognizing the emotional reality of dying, will be relaxed for some Medicare patients under an experiment to see whether concurrent coverage of curative and hospice care reduces costs and increases the quality of care.

The CMS experiment, scheduled to start in January and run through 2020, will allow about 140 hospices across the U.S. to care for patients who may also continue curative treatment with the potential to slow their disease and prolong life. The test, known as the Medicare Care Choices Model, will include as many as 150,000 patients and was launched under the Affordable Care Act.

The initiative will roll out in two phases with the first hospices entering in January and a second wave to begin in January 2018. Conditions qualifying patients for participation include cancer, congestive heart failure, chronic obstructive pulmonary disease and HIV/AIDS. So many hospice providers expressed an interest in participating that the CMS increased the possible roster to 140 hospice providers from the original limit of 30.

The way the program is structured, with some hospices starting the program in 2016 and the rest starting two years later, will allow the CMS to compare outcomes between the two groups and a third group of hospices not participating. Dr. Patrick Conway, the CMS' chief medical officer, told the New York Times that the design will make it possible to do a more robust evaluation of the program and determine whether it should be expanded to all Medicare beneficiaries and hospices.

Experts say the new program recognizes that lines increasingly have blurred between curative and palliative treatments. For instance, blood transfusions may prevent fatigue for bone-marrow disease patients so they can better enjoy their remaining days, said Dr. Steven Oppenheim, medical director of palliative medicine at the Banner Thunderbird Medical Center in Glendale, Ariz. Under the experimental program, patients will be able to continue those transfusions while receiving the hospice benefit.

The hope is that the new initiative will encourage a higher percentage of dying patients to take advantage of hospice and that doctors will refer them earlier. Last year, the CMS said only 44% of Medicare patients used the hospice benefit at the end of life. Most use it for only a short period of time. Some research shows that African-Americans and other minorities are even less likely to use hospice services.

Under Medicare rules, doctors may refer patients for hospice coverage when they have a prognosis of six months or less to live. But in 2013, Medicare patients' median length of stay in a hospice was only 17 days. Among Medicare cancer patients who enter hospice, half do so with less than three weeks to live, and 1 out of 10 enters hospice within three days of dying. Oncologists consider such brief use of hospice a measure of poor quality of care.

There's broad consensus that hospice care improves quality of care for dying patients and their families. A study published in 2010 in the New England Journal of Medicine found that among patients with metastatic nonsmall-cell lung cancer, early palliative care led to significant improvements in quality of life and mood compared with patients receiving standard care. The patients receiving the early palliative care had longer survival despite receiving less aggressive care at the end of life.

Whether the Care Choices Model will save money is another question. Medicare spending on hospice increased about 50% from $10.1 billion in 2007 to $15.1 billion in 2013, according to the CMS. There have been increasing concerns about hospice costs, with some research showing that the growing dominance of for-profit providers has been associated with rising utilization and costs.

The new program may save money by helping patients avoid emergency department visits and hospitalizations when they experience medical crises, said Melissa Aldridge, an associate professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, who has studied differences in enrollment rates between for-profit and not-for-profit hospice providers.

Hospice providers can work more closely with patients and caregivers to prevent those crises, she said.

Under the initiative, hospices, instead of getting a per diem payment, will receive a Medicare monthly payment of $200 to

$400 per patient for any hospice care that patients need. Meanwhile, other providers can still bill Medicare for curative services.

The model also will allow patients to access alternatives to medical intervention or drugs—such as massage therapy for pain—that Medicare won't otherwise pay for, said Pamela Halvorson, president of Fairview Home Care & Hospice in Minneapolis.

Patient preferences aren't the only reason for underuse of hospice services. Medicare typically pays hospices a per diem rate, which has also been cited as a factor. A study published in Health Affairs found that 3 out of 4 hospices surveyed in 2008 and 2009 reported policies that would exclude complex patients who need transfusions, palliative chemotherapy, tube feeding and other costly services.

The Care Choices Model will allow patients to enter hospice before they fully come to terms with their terminal prognosis, experts say. For seriously ill patients, the choice of when to stop treatment can be murky. How patients come to accept dying is profoundly personal. A prognosis may be overshadowed by religious beliefs, emotional turmoil or how well someone feels, and family members' views and desires, regardless of the patient's deteriorating health.

Recent studies highlight how widely patients' perceptions of their health can deviate from the medical facts. “Sometimes those can be really, really far apart,” said Rafael Romo, a nurse and quality scholar fellow at the San Francisco Veterans Affairs Medical Center.

He cited a 2011 randomized controlled trial of palliative care combined with cancer treatment versus only cancer treatment. Half the patients reported being “relatively healthy” at the start and only 13% reported a terminal illness, despite having metastatic nonsmall-cell lung cancer, which has an estimated prognosis of one year from when patients are diagnosed.

A separate analysis of those patients found two-thirds of those same patients reported their goal for care was a cure. One-third reported their cancer could be cured, despite a diagnosis with the likelihood they would not survive more than a year.

Romo said the Medicare Care Choices Model will allow patients “time to adjust” with support from hospice providers, who include social workers, clergy and bereavement counselors. Even for patients who don't believe they will die, additional time allows for repeated conversations to help patients identify their goals for medical intervention and more clearly understand their condition. “They'll be able to see their health in a more realistic way,” he said.

Research published this month in JAMA Oncology found chemotherapy did not improve the quality of life for patients in their final days. Indeed, for those patients least debilitated by cancer, chemotherapy worsened their quality of life.

The new model will give patients and their families more time to build trust with the social workers, nurses and doctors on the hospice team, Banner's Oppenheim said. That trust can help with acceptance of the dying process and improve the quality of the patient's remaining days, he added.

“Hospice really has a lot more to offer patients and families” than can be experienced in two weeks, which is the median time patients spend in hospice, he said. “It's a rush job at the end.”