Even among the experts who were most supportive of testing new payment models, there were concerns that there might not be much utility in testing a model that doesn’t reimburse for the intensity of services that clinical research shows help patients.
“I believe a good model provides enough reimbursement to provide the services that are required,” said Dr. Joe Rotella, chief medical officer at the American Academy of Hospice and Palliative Medicine. “Any model that is underfunded has little chance of achieving its goal.”
Without adequate funding, hospices can only provide concurrent care to a small number of beneficiaries because it’s too risky financially. That doesn’t benefit patients, hospice providers or providers delivering curative services. It probably wouldn’t reduce Medicare spending either if patients continue to receive curative care until the very end of life.
It’s also possible that payment models with low reimbursements could create perverse financial incentives. Hospice providers might try to accelerate their patients’ transition from concurrent to traditional hospice care if they’re reimbursed far below the cost of providing high-quality hospice. That could undermine patient choice, a vital feature of these new models. Or result in other unintended consequences.
Hospice providers think that focusing on the value of care rather than the cost of care would improve the model. They argue that Congress should pass legislation permitting CMMI to test models that improve quality and patient satisfaction, even if they’re not cost-neutral or cost-saving.
Experts also wonder if a prognosis is the best way to determine who’s eligible to receive hospice care.
“Providers are really hesitant to frame it that way” VandeKieft said. “They feel like it’s going to take away hope.”
He also cautioned that patients may be less likely to consider hospice if it’s associated with a prognosis.
The current six-month prognosis standard was established by the Office of Management and Budget as a cost-saving measure decades ago. OMB didn’t base it on clinical efficacy. So the people who provide hospice care say this artificially limits who can benefit from hospice and may cost more money in the long run by limiting access to care.
Forster suggested that expanding the prognosis requirement to one year could be enough to provide a smoother transition to end-of-life care by allowing patients seeking curative care to experience the benefits of hospice sooner, a sentiment echoed by some of her colleagues.
Others don’t think this goes far enough. They argue that basing access to hospice care on patient need rather than the prognosis is a better method. Payment models based on patient needs would likely consider whether a patient has a serious illness and a high demand for additional care. Evidence of high need might include function, the need for caregiving, troublesome symptoms, and rehospitalizations or emergency medical situations. These could be better markers for who would benefit from hospice care.
However, developing payment models based on patient needs would require objective needs-based assessments based on function, which isn’t routinely collected for patients with serious illness. It’s only recorded when patients enter certain types of care like hospice.
“It’s hard to find that in patients’ medical records,” Rotella said. “It’s also hard to get that from looking at their claims data.”
Moving to a hospice payment system based on need would require a regular collection of data on function and the activities of daily living for people living with serious illness. Right now, there’s no way for a physician to know the baseline function of a patient before an acute episode. That makes it impossible to know how much need a seriously ill patient might have or for how long.
If providers know that seriously ill patients are having difficulties with their everyday activities, they might be able to connect them with support services before an acute episode occurs. Or, if a patient is seriously ill but high functioning, they might only receive supportive care through hospice services until they no longer needed it. Under that scenario, hospice access would be more like physical therapy, which is based on need rather than prognosis.
There are also some barriers to increasing hospice utilization that can’t be easily addressed by new payment models. Many physicians who treat patients with serious illness have little to no formal education about hospice. Including hospice training as part of medical education or providing specialized training to more doctors could increase its prevalence as a viable treatment option for seriously ill patients.
There are also technological barriers. A lack of certified, interoperable and hospice-specific electronic health records makes it difficult for hospices to integrate with other providers. It’s not clear who should pay for the upgrades, but hospices say they can’t afford it. They think that financial incentives or new standards that encourage EHR vendors to develop certified, interoperable and hospice-specific systems could inspire more concurrent care under new payment models.
The CMS earlier this year acknowledged the technological and financial issues surrounding adoption of certified EHRs in post-acute settings. It issued two requests for information to gather industry feedback to identify and develop solutions. The CMS said previously that the lack of post-acute EHR adoption is probably caused by an absence of federal incentives under the Medicare and Medicaid EHR Incentive Programs.
The CMMI recently introduced new APMs that don’t target hospice care to the same extent as MCCM but would likely have an impact on hospice utilization. These include the Medicare Advantage Value-Based Insurance Design Model and Primary Care First.
The Medicare Advantage VBID program includes a carve-in for hospice care among other new benefits—the current Medicare Advantage program doesn’t cover hospice. Under Primary Care First, the CMS will reimburse providers, including Medicare-enrolled clinicians who usually deliver hospice or palliative care, to take responsibility and coordinate care for seriously ill patients who lack a primary-care practitioner. Most providers are waiting for more details about each of the models before they evaluate them.
The CMS designed each of these programs to reward providers for the value they provide to patients rather than reimbursing them for the volume of services they deliver.
So while the details of them aren’t known yet, one thing has become clear: “A lot of the gaps in the healthcare system are gaps in supportive services,” said Edo Banach, CEO of the National Hospice and Palliative Care Organization. “It’s often human to human interaction that makes the difference.”
Providence St. Joseph’s Warren believes that her system’s experience with the MCCM in California’s Orange County has established them as a community leader in hospice care by showing that they can do more than traditional hospice and through partnerships with local specialists. She thinks that’s positioned them well for any of the new hospice models.
“We already have existing relationships … we are already on a path,” Warren said. The new models are “a huge opportunity to evolve how we deliver care for people who are seriously ill.”