Some hospice advocates and providers are concerned that too few Medicare beneficiaries will qualify for a CMS experiment allowing terminally ill patients to continue curative treatment after starting hospice care.
Medicare patients currently are required to forgo curative services when they enroll in a hospice program to receive palliative care during the dying process. But studies have found that providing both forms of care concurrently improves quality of life and reduces costs since those patients tend to not make frequent hospital visits.
Under a demonstration administered by the CMS Innovation Center, Medicare is paying a select group of hospices $400 per beneficiary per month for palliative services while also allowing providers and suppliers of curative services to bill Medicare.
The experiment formally kicked off Jan. 1, but hospices are already saying the CMS must loosen the eligibility criteria.
“Unfortunately, the early indication from the first group of 71 hospice awardees is that this demonstration has been constructed too narrowly, and that CMS has so tightly managed it that few patients' are able to participate,” Don Schumacher, CEO of the National Hospice and Palliative Care Organization, said in a letter (PDF)to Dr. Patrick Conway, the CMS' deputy administrator for innovation and quality.
The trade group is made up of not-for-profit hospice and palliative-care programs. The letter was also sent to Congress.
A patient must meet 14 individual requirements before he or she can be enrolled in the demonstration. For instance, the demonstration is only open to individuals diagnosed with late-stage cancer, chronic obstructive pulmonary disease, HIV or congestive heart failure who are otherwise hospice-eligible.
Only a third of hospice-eligible beneficiaries have one of these diagnoses, according to the most recent Medicare hospice data.
Individuals also must be enrolled in a stand-alone Medicare Part D prescription drug plan to qualify for the demonstration, which is the case for just 45% of Medicare beneficiaries.
Schumacher said the CMS should revisit the structure because National Hospice and Palliative Care Organization member hospices say they have struggled to find beneficiaries that meet all 14 criteria.
“At this time, enrollment is dangerously low,” Schumacher wrote in the letter. “Surely this is not what Congress intended when it authorized this program, nor is it instructive to CMS or policymakers on how they can better coordinate curative and palliative care for individuals with advanced illness and at the end of life.”
Paul Malley, president of Aging with Dignity, a national advocacy group has heard similar concerns. “Patients shouldn't have to jump through hoops to get quality care at the end of life,” he said.
Others, however, said it's premature to start ringing alarms about the way the program is structured.
“It's awfully early to be drawing sweeping conclusions,” said Dr. Cameron Muir, chief medical officer at Capital Caring, a large, not-for-profit hospice organization in Washington, D.C. “I'd be very interested to see going forward if there is much better adoption. It's only been 10 weeks.”
Marian Grant, director of policy and professional engagement at the Coalition to Transform Advanced Care, said now is the right time to make changes that would give the program a better chance of being successful. The sooner the demonstration shows results, the quicker it can be expanded, she said.
The Coalition to Transform Advanced Care is made up of health insurance companies, hospital systems, consumer organizations and faith-based groups that aim to reform advanced illness and end-of-life care.
Grant, who received a fellowship to help the CMS Innovation Center with marketing materials for the demonstration, said the agency wanted to limit eligibility because of rising Medicare hospice costs.
In 2014, more than 1.3 million Medicare beneficiaries received hospice services from over 4,000 providers and Medicare hospice expenditures totaled about $15.1 billion, up from 1.2 million Medicare beneficiaries and $13.8 billion in expenditures in 2011.
However, Grant said she is optimistic the CMS may lower some of the barriers to the programs if enough evidence is submitted that too few are able to take advantage of the program.
A CMS spokesman did not immediately return a request for comment.