JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 10, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2014.0268
Hospice Innovation Impediments: Can Halfway Efforts Tame the Terrible Choice? Dale E. Lupu, MPH, PhD,1 Barbara Ivanko, LCSW, CHPCA,2 Franco Insana, MBA, CPA,2 Patrick H. White, MD,2,3 and Robert M. Arnold, MD 4,5
Dear Editor: We greeted the March 2014 announcement of the Medicare Care Choices Model (MCCM) demonstration project1 with enthusiasm and hope. Here was an opportunity, under the auspices of the Innovation Center of the Center for Medicare and Medicaid Services, to experiment with expanding access to hospice services for patients still pursuing curative treatments. Unfortunately, as the terms of the demonstration became clearer, we realized that the rules are unlikely to lead to the innovative changes needed to improve access to hospice. In this article we explain the specific problems with the MCCM, calculate the financial risk that would be imposed on participating hospices, and make recommendations for improving the MCCM so that true innovation in hospice care can be tested. Medicare rules require patients to give up regular Medicare benefits in order to receive hospice care. This is widely perceived as a ‘‘terrible choice’’ between curative and comfort care, leading to suboptimal access to hospice.2,3 Although almost half of Medicare decedents use hospice, half of those enroll two to three weeks before death, and a quarter die within a week of enrolling in hospice.4 This ‘‘brink of death’’ hospice care results in lost opportunities both to improve patients’ and families’ quality of life and to decrease health care costs.5 The hypothesis behind the MCCM demonstration is that education, gentle encouragement, and relationship building between the hospice and the patient/family will reduce patient/family concerns about ‘‘giving up’’ regular Medicare benefits and increase their willingness to forgo costly and ineffectual treatment. Other payers including Aetna,6 Kaiser,7 Sutter,8 and the Veterans Administration9 have tried this with success. They have used more flexible admission criteria combined with case management to promote both earlier enrollment and cost savings. The MCCM demonstration seeks to replicate these successes. The MCCM directs hospices to provide care planning and case management services to eligible Medicare benefi-
ciaries (those with an expected life prognosis of six months or less) who have had at least two hospitalizations within the past year but have not yet elected hospice. The demonstration pays the hospice a monthly fee of $400 per enrolled beneficiary—the reported cost of the Aetna program.4 Unfortunately, CMS introduced a critical twist to the Aetna program that makes participation in the demonstration risky financially. Along with the case management provided by Aetna, hospices are required to provide the full scope of usual home hospice care (nursing visits, social work and counseling, spiritual care, home health aide visits, inpatient respite care, 24/7 on-call service, volunteers). From a continuity point of view, this makes sense: having patients and families get to know hospice staff makes transitioning to hospice easier. But the hospices are expected to provide these resources—with no additional reimbursement. The first problem is financial. Hospices are typically paid about $150 per patient, per day, to deliver hospice services (along with medications, supplies, or DME, which are not required under the demonstration). MCCM is requiring hospices to provide this care—for less than a tenth of their usual reimbursement. Medicare may think that prior to entering hospice patients aren’t that sick. In our experience, patients in a ‘‘pre-hospice’’ palliative home health program have complex needs, requiring care coordination, symptom management, and hands-on help with caregiving. Medicare may also assume that any increased costs will be offset by earlier hospice enrollment. While this may be true, it is a large bet for hospices to take just to break even, and prudent hospices will need to be prepared to heavily subsidize the demonstration should enrollees have more complex needs than Medicare envisions. We calculated the expected loss under three different care need scenarios using the expense experience of the hospice several of the authors are associated with (see Table 1). We then calculated the number of additional hospice days that would be needed to offset demonstration losses at varying
1
Center for Aging, Health and Humanities, George Washington University, Washington, DC. Family Hospice & Palliative Care, Pittsburgh, Pennsylvania. 3 Clinical and Translational Science Program, University of Pittsburgh, Pittsburgh, Pennsylvania. 4 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. 5 Supportive and Palliative Care Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. 2
1088
1089
Revenue MCCM reimbursement @ $400/month # months MCCM revenue Physician visits @ $80/visit # visits Physician revenue Total revenue (physician visits @ $80/visit; MCCM reimbursement @ $400/month) Expenses Number of visits in person over 3 months Number of hours for inperson visits Number of hours for phone calls and case management Direct care staff costs Overhead @ 35% Total expenses Net revenue over/(under) expenses Hospice contribution to fixed expense per patient day Additional hospice days needed to break even 100% conversion rate 75% conversion 50% conversion 25% conversion
Scenario description
27 $1,739 $609 $2,348 ($988) $65
27 $1,436 $503 $1,939 ($659) $65
15.2 20.3 30.4 60.8
29
20
10.1 13.5 20.2 40.4
24
15
2 $160 $1,360
1 $80 $1,280
108.5 144.7 217.0 434.0
$65
$6,230 $2,181 $8,411 ($7,051)
Full hospice care @ $69.22/ day for staff · 90 days
2 $160 $1,360
3 $1,200
Needs same level of care as average hospice patient throughout 90 day period of care.
Needs more home health aide assistance (2.5 times per week in last month) than telephonic case. In 3 months, assumes 2 MD visits, 24 home visits (29 hours), 27 phone hours for case management.
3 $1,200
Many care needs
Mix of telephone calls and visits
3 $1,200
After admission (including care planning), most needs handled by telephone call only. No home health aide until last month. In 3 months, assumes 1 MD visit, 15 home visits (20 hours), 27 phone hours for case management.
Telephonic case management only
Table 1. Forecast of Net Revenue and Number of Hospice Days Needed To Recoup Losses Under Different Care Need Assumptions for MCCM
1090
rates of ‘‘conversion’’ to hospice. At a 50% conversion rate, the demonstration losses could be recouped only if patients entered hospice care at least 20 days earlier for the telephonic case management scenario, 30 days earlier for a most-likely mix of telephone and visits, and 217 days earlier for a scenario where enrollees need the equivalent of hospice care. If our assumptions are realistic, hospices participating in the demonstration risk losing between $65,900 to $705,100 for every 100 patients enrolled in the project. This is not tenable for most hospices and may be why hospices are reluctantly unenthusiastic about the program. The second, more serious problem is that this demonstration is only a halfway effort to innovate. It maintains most of the 30-year-old structure of the Medicare Hospice Benefit that limited access all along. Despite physicians’ inability to prognosticate six-month survival, CMS retains the same hospice eligibility criteria. This demonstration, in the end, still requires patients to give up ‘‘curative’’ therapy to enroll in hospice. Patients who actually are receiving benefit from disease-directed therapies are unlikely to give those therapies up. For example, patients with congestive heart failure often find those disease-directed therapies helpful for quite a long time. As these therapies are not affordable under the current hospice rate, these patients will still want to wait before entering hospice. How might the program be changed to achieve its goals of promoting earlier access and efficiency? First, the program needs a reimbursement model that takes into account that the hospices will be providing home-based services for these very sick patients. The new economic reality in medicine is that while health care organizations are going to be at financial risk, they will also be able to gain if they do the right thing and promote patient quality of life. Hospices should be able to share in the savings as long as they meet clinical metrics and have high patient satisfaction ratings. Concerns that new services will only add to total cost could be met by requiring a hospice to provide the services within the current ‘‘cap’’ on hospice care costs. Second, we urge CMS to allow hospices to propose a broader range of truly innovative changes to remove current barriers to enrollment These might include an ‘‘open access’’ model or comanagement strategy. True, these models might not work or might prove too costly. But that is the purpose of the Innovation Center—to test bold solutions and winnow out the best. Medical care for seriously ill patients has changed in the last 30 years. The current MCCM is a tentative and small
LUPU ET AL.
step toward testing the changes that hospices and Medicare need to make together to adapt to the new needs of patients and providers. A more flexible, forward-looking, and balanced set of requirements for the demonstration would serve CMS, the hospice community, and potential patients better than the very restrictive model CMS proposes. We urge the Innovation Center to live up to its name and create a program that invites creative innovation from hospices so that they can find new ways of providing the best care to patients. References
1. Medicare Center for Medicare & Medicaid Innovation: Care Choices Model. 2014. 2. Casarett DJ, Fishman JM, Lu HL, et al.: The terrible choice: Re-evaluating hospice eligibility criteria for cancer. J Clin Oncol 2009;27:953–959. 3. Wright A, Katz I: Letting go of the rope: Aggressive treatment, hospice care, and open access. N Engl J Med 2007; 357:324–327. 4. Medicare Payment Advisory Commission: Report to the Congress: Medicare Payment Policy. 2014. 5. Kelley AS, Deb P, Du Q, et al.: Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff 2013;32:552–561. 6. Spettell CM, Rawlins WS, Krakauer R, et al.: A comprehensive case management program to improve palliative care. J Palliat Med 2009;12. 7. Engelhardt JB, Rizzo VM, Della Penna RD, et al.: Effectiveness of care coordination and health counseling in advancing illness. Am J Manag Care 2009;15:817–825. 8. Ciemins EL, Stuart B, Gerber R, et al.: An evaluation of the Advanced Illness Management (AIM) program: Increasing hospice utilization in the San Francisco Bay area. J Palliat Med 2006;9:1401–1411. 9. Lorenz K, Malin JL: How might VA-Medicare differences inform the delivery of end-of-life cancer care? Cancer 2010;116:3533–3536.
Dale E. Lupu, MPH, PhD Center for Aging, Health, and Humanities George Washington University 2030 M Street NW, Suite 300 Washington, DC 20036 E-mail: [email protected]
Hospice Innovation Impediments: Can Halfway Efforts Tame the Terrible Choice? Dale E. Lupu, MPH, PhD,1 Barbara Ivanko, LCSW, CHPCA,2 Franco Insana, MBA, CPA,2 Patrick H. White, MD,2,3 and Robert M. Arnold, MD 4,5
Dear Editor: We greeted the March 2014 announcement of the Medicare Care Choices Model (MCCM) demonstration project1 with enthusiasm and hope. Here was an opportunity, under the auspices of the Innovation Center of the Center for Medicare and Medicaid Services, to experiment with expanding access to hospice services for patients still pursuing curative treatments. Unfortunately, as the terms of the demonstration became clearer, we realized that the rules are unlikely to lead to the innovative changes needed to improve access to hospice. In this article we explain the specific problems with the MCCM, calculate the financial risk that would be imposed on participating hospices, and make recommendations for improving the MCCM so that true innovation in hospice care can be tested. Medicare rules require patients to give up regular Medicare benefits in order to receive hospice care. This is widely perceived as a ‘‘terrible choice’’ between curative and comfort care, leading to suboptimal access to hospice.2,3 Although almost half of Medicare decedents use hospice, half of those enroll two to three weeks before death, and a quarter die within a week of enrolling in hospice.4 This ‘‘brink of death’’ hospice care results in lost opportunities both to improve patients’ and families’ quality of life and to decrease health care costs.5 The hypothesis behind the MCCM demonstration is that education, gentle encouragement, and relationship building between the hospice and the patient/family will reduce patient/family concerns about ‘‘giving up’’ regular Medicare benefits and increase their willingness to forgo costly and ineffectual treatment. Other payers including Aetna,6 Kaiser,7 Sutter,8 and the Veterans Administration9 have tried this with success. They have used more flexible admission criteria combined with case management to promote both earlier enrollment and cost savings. The MCCM demonstration seeks to replicate these successes. The MCCM directs hospices to provide care planning and case management services to eligible Medicare benefi-
ciaries (those with an expected life prognosis of six months or less) who have had at least two hospitalizations within the past year but have not yet elected hospice. The demonstration pays the hospice a monthly fee of $400 per enrolled beneficiary—the reported cost of the Aetna program.4 Unfortunately, CMS introduced a critical twist to the Aetna program that makes participation in the demonstration risky financially. Along with the case management provided by Aetna, hospices are required to provide the full scope of usual home hospice care (nursing visits, social work and counseling, spiritual care, home health aide visits, inpatient respite care, 24/7 on-call service, volunteers). From a continuity point of view, this makes sense: having patients and families get to know hospice staff makes transitioning to hospice easier. But the hospices are expected to provide these resources—with no additional reimbursement. The first problem is financial. Hospices are typically paid about $150 per patient, per day, to deliver hospice services (along with medications, supplies, or DME, which are not required under the demonstration). MCCM is requiring hospices to provide this care—for less than a tenth of their usual reimbursement. Medicare may think that prior to entering hospice patients aren’t that sick. In our experience, patients in a ‘‘pre-hospice’’ palliative home health program have complex needs, requiring care coordination, symptom management, and hands-on help with caregiving. Medicare may also assume that any increased costs will be offset by earlier hospice enrollment. While this may be true, it is a large bet for hospices to take just to break even, and prudent hospices will need to be prepared to heavily subsidize the demonstration should enrollees have more complex needs than Medicare envisions. We calculated the expected loss under three different care need scenarios using the expense experience of the hospice several of the authors are associated with (see Table 1). We then calculated the number of additional hospice days that would be needed to offset demonstration losses at varying
1
Center for Aging, Health and Humanities, George Washington University, Washington, DC. Family Hospice & Palliative Care, Pittsburgh, Pennsylvania. 3 Clinical and Translational Science Program, University of Pittsburgh, Pittsburgh, Pennsylvania. 4 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. 5 Supportive and Palliative Care Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. 2
1088
1089
Revenue MCCM reimbursement @ $400/month # months MCCM revenue Physician visits @ $80/visit # visits Physician revenue Total revenue (physician visits @ $80/visit; MCCM reimbursement @ $400/month) Expenses Number of visits in person over 3 months Number of hours for inperson visits Number of hours for phone calls and case management Direct care staff costs Overhead @ 35% Total expenses Net revenue over/(under) expenses Hospice contribution to fixed expense per patient day Additional hospice days needed to break even 100% conversion rate 75% conversion 50% conversion 25% conversion
Scenario description
27 $1,739 $609 $2,348 ($988) $65
27 $1,436 $503 $1,939 ($659) $65
15.2 20.3 30.4 60.8
29
20
10.1 13.5 20.2 40.4
24
15
2 $160 $1,360
1 $80 $1,280
108.5 144.7 217.0 434.0
$65
$6,230 $2,181 $8,411 ($7,051)
Full hospice care @ $69.22/ day for staff · 90 days
2 $160 $1,360
3 $1,200
Needs same level of care as average hospice patient throughout 90 day period of care.
Needs more home health aide assistance (2.5 times per week in last month) than telephonic case. In 3 months, assumes 2 MD visits, 24 home visits (29 hours), 27 phone hours for case management.
3 $1,200
Many care needs
Mix of telephone calls and visits
3 $1,200
After admission (including care planning), most needs handled by telephone call only. No home health aide until last month. In 3 months, assumes 1 MD visit, 15 home visits (20 hours), 27 phone hours for case management.
Telephonic case management only
Table 1. Forecast of Net Revenue and Number of Hospice Days Needed To Recoup Losses Under Different Care Need Assumptions for MCCM
1090
rates of ‘‘conversion’’ to hospice. At a 50% conversion rate, the demonstration losses could be recouped only if patients entered hospice care at least 20 days earlier for the telephonic case management scenario, 30 days earlier for a most-likely mix of telephone and visits, and 217 days earlier for a scenario where enrollees need the equivalent of hospice care. If our assumptions are realistic, hospices participating in the demonstration risk losing between $65,900 to $705,100 for every 100 patients enrolled in the project. This is not tenable for most hospices and may be why hospices are reluctantly unenthusiastic about the program. The second, more serious problem is that this demonstration is only a halfway effort to innovate. It maintains most of the 30-year-old structure of the Medicare Hospice Benefit that limited access all along. Despite physicians’ inability to prognosticate six-month survival, CMS retains the same hospice eligibility criteria. This demonstration, in the end, still requires patients to give up ‘‘curative’’ therapy to enroll in hospice. Patients who actually are receiving benefit from disease-directed therapies are unlikely to give those therapies up. For example, patients with congestive heart failure often find those disease-directed therapies helpful for quite a long time. As these therapies are not affordable under the current hospice rate, these patients will still want to wait before entering hospice. How might the program be changed to achieve its goals of promoting earlier access and efficiency? First, the program needs a reimbursement model that takes into account that the hospices will be providing home-based services for these very sick patients. The new economic reality in medicine is that while health care organizations are going to be at financial risk, they will also be able to gain if they do the right thing and promote patient quality of life. Hospices should be able to share in the savings as long as they meet clinical metrics and have high patient satisfaction ratings. Concerns that new services will only add to total cost could be met by requiring a hospice to provide the services within the current ‘‘cap’’ on hospice care costs. Second, we urge CMS to allow hospices to propose a broader range of truly innovative changes to remove current barriers to enrollment These might include an ‘‘open access’’ model or comanagement strategy. True, these models might not work or might prove too costly. But that is the purpose of the Innovation Center—to test bold solutions and winnow out the best. Medical care for seriously ill patients has changed in the last 30 years. The current MCCM is a tentative and small
LUPU ET AL.
step toward testing the changes that hospices and Medicare need to make together to adapt to the new needs of patients and providers. A more flexible, forward-looking, and balanced set of requirements for the demonstration would serve CMS, the hospice community, and potential patients better than the very restrictive model CMS proposes. We urge the Innovation Center to live up to its name and create a program that invites creative innovation from hospices so that they can find new ways of providing the best care to patients. References
1. Medicare Center for Medicare & Medicaid Innovation: Care Choices Model. 2014. 2. Casarett DJ, Fishman JM, Lu HL, et al.: The terrible choice: Re-evaluating hospice eligibility criteria for cancer. J Clin Oncol 2009;27:953–959. 3. Wright A, Katz I: Letting go of the rope: Aggressive treatment, hospice care, and open access. N Engl J Med 2007; 357:324–327. 4. Medicare Payment Advisory Commission: Report to the Congress: Medicare Payment Policy. 2014. 5. Kelley AS, Deb P, Du Q, et al.: Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff 2013;32:552–561. 6. Spettell CM, Rawlins WS, Krakauer R, et al.: A comprehensive case management program to improve palliative care. J Palliat Med 2009;12. 7. Engelhardt JB, Rizzo VM, Della Penna RD, et al.: Effectiveness of care coordination and health counseling in advancing illness. Am J Manag Care 2009;15:817–825. 8. Ciemins EL, Stuart B, Gerber R, et al.: An evaluation of the Advanced Illness Management (AIM) program: Increasing hospice utilization in the San Francisco Bay area. J Palliat Med 2006;9:1401–1411. 9. Lorenz K, Malin JL: How might VA-Medicare differences inform the delivery of end-of-life cancer care? Cancer 2010;116:3533–3536.
Dale E. Lupu, MPH, PhD Center for Aging, Health, and Humanities George Washington University 2030 M Street NW, Suite 300 Washington, DC 20036 E-mail: [email protected]
