New hospice trial shows promise, but questions remain

Despite limited participation among terminally ill seniors, healthcare professionals are hopeful that a new payment model will get more people to use and benefit from hospice care.

For more than a decade, advocates have called for reforms to the way the CMS pays for hospice care because less than half of eligible Medicare beneficiaries use it. Even among those who do, half of them are admitted within the last two weeks of life. That’s far less than the six months allowed under the existing Medicare Hospice Benefit.

So the CMS is experimenting with alternative payment models for hospice and other post-acute settings in its pursuit to increase clinical integration throughout the care continuum. A five-year trial that began in January 2016, the Medicare Care Choices Model, allows beneficiaries to enroll in hospice care while continuing to receive curative care for their terminal illness such as chemotherapy or dialysis.

“The concurrent care concept is rock solid,” said Dr. Gregg VandeKieft, medical director for palliative care for Providence St. Joseph Health’s southwest Washington service area and associate medical director of Providence St. Joseph’s Institute for Human Caring.

The MCCM pays hospices a monthly fee between $200 and $400 to provide care for each beneficiary enrolled in the program. It was created to address growing concerns that patients are declining hospice care under the existing Medicare Hospice Benefit because it requires them to go without curative care, even though hospice is associated with better quality outcomes and lower healthcare costs.

“That line between what’s curative and what’s palliative, it’s a lot grayer than it was years and years ago,” said Terri Warren, Providence St. Joseph’s chief of palliative and hospice care.

Research shows that Medicare fee-for-service patients who receive hospice care have lower hospitalization rates, are less likely to be admitted to an intensive-care unit and have fewer invasive procedures at the end of life. Their healthcare expenditures are also about $13,000 lower during their last year of life, according to a 2014 study in the Journal of the American Medical Association.

“It only takes one or two ICU stays and you can pay for … the type of care that hospice provides,” VandeKieft said.

The CMS hopes the trial payments will give more people access to hospice-provided supportive care services, increase the quality of life and satisfaction for patients and families, and spur new payment systems for Medicare and Medicaid.

The program hit some snags early on. A September 2018 report found that more than a quarter of the hospices that participated in the program dropped out after the first year because the payments were too low, and the eligibility criteria were too narrow. The CMS originally expected as many as 150,000 patients to get hospice care under the program, but referrals barely hit 5,000 by June 2017 and only about 2,000 of them were eligible. Roughly 1,100 Medicare beneficiaries chose to enroll.

Still many hospice experts support the initiative because they believe it serves as a proof of concept and provides valuable data for future payment systems.

“It definitely shows that there’s promise in using these types of models to support patients,” said Theresa Forster, vice president for hospice policy and programs at the National Association for Home Care & Hospice.

Roughly 4 out of 5 beneficiaries in the MCCM chose the Medicare Hospice Benefit after an average of two months in the program and spent one month in hospice, which is double the length of the typical hospice stay. The average age of people in the MCCM program was also about five years younger than the average hospice patient. That difference hints that being able to seek concurrent care opened hospice to a new demographic, according to Forster.

The MCCM also seemed to help people who were hesitant about hospice become more comfortable with it earlier in their disease trajectory. It’s also easier for patients to transition to hospice because the same care team typically provides care under both the MCCM and the original hospice benefit. Historically, people have been tentative to give up curative care because it also meant switching care teams at a vulnerable time in their lives.

“When you ask someone to switch to a whole new team of providers, that’s scary,” said Dale Lupu, a research professor at the George Washington University Center for Aging, Health and Humanities.

Lupu added that as patients become more comfortable with hospice care, they’re more willing to stop curative treatment because as a patient, “I know I can call you … I know you’re going to be there for me.”

“Patients are always incredibly grateful,” VandeKieft said. And one of the benefits of providing supportive care to a patient that’s receiving life-prolonging treatment is that doctors and others can provide it and “not feel like I have to pull the rug out from underneath them,” VandeKieft added.

Warren says that management teams need to be agile and creative to succeed under the MCCM and other nontraditional hospice models. They require a different operational approach and there needs to be a focus on communication and investment from providers across the board in coordinating care. Her organization has succeeded by concentrating on key relationships with a small number of select specialists in the community.

“By sharing feedback, especially from families that participate in the program, that has really paved the path for a referral relationship,” Warren said.

There are some early indications that the program is achieving its goals of improving quality and patient satisfaction while reducing spending, although the CMS won’t likely issue an updated report until later this year.

Nevertheless, some hospice providers and experts have reservations about the approach of the MCCM and other APMs because under the Affordable Care Act, the Center for Medicare and Medicaid Innovation can only consider payment models that are likely to maintain or cut Medicare spending.

That limits what types of policies the CMMI will develop and test since they can’t experiment with models that might increase spending, even if they provide additional quality and patient-satisfaction benefits.

Several experts said that hospice care is held to a different standard than other forms of treatment because it’s required to show how it decreases spending rather than being evaluated on the benefits of the treatment.

“If there’s a new heart medicine that comes out and it’s shown to be effective … we don’t say, ‘We’ll only pay for your heart medicine if you stop taking your blood pressure medicine,’ ” Lupu said.

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.”