Hospice pilot provides for concurrent curative therapies

January 15, 2016


As many as 150,000 people nearing end of life will have access to an extra layer of services under the Medicare Care Choices Model, a pilot program for Medicare patients who have been diagnosed with one of four terminal illnesses and want to receive treatment designed to cure their illness and a modified hospice benefit.

"What makes this program different than hospice is that curative care is ongoing," said Dr. Kathleen Benton, director of clinical ethics at St. Joseph's/Candler Health System in Savannah, Ga.

About 140 hospices will participate in the program, including ministry members SSM Health at Home, based in St. Louis; Catholic Hospice of Miami Lakes, Fla.; Lourdes Home Care and Hospice in Paducah, Ky.; Mount Carmel Hospice and Palliative Care in Columbus, Ohio; Hospice of Siouxland in Sioux City, Iowa; Mercy Hospital Jefferson in Festus, Mo.; Providence Hospice in Hood River, Ore.; and Providence Hospice of Seattle. About half of the 140 hospices were scheduled to begin to offer the program this month. The rest will begin in 2018.

Walter Frank Bennett, left, talks with Richard Dederer, veterans program coordinator for SSM Health at Home – Hospice. Dederer visits Bennett in his Wentzville, Mo., home as part of the "We Honor Veterans" program.

The original plan from the Centers for Medicare and Medicaid Services called for just 30 hospices to participate in the five-year program, but CMS expanded enrollment because of high interest. The demand highlights openness to an alternative to the black-and-white decision that patients and families have faced in the past. To receive Medicare's standard hospice benefits, a patient must halt curative treatment. Many people resist the decision to forego curative care.

Promoting hospice enrollment
"People come very, very late to hospice and often only after they have had multiple hospitalizations," said Dr. Diane Meier, director of the Center to Advance Palliative Care in New York. "So it was a forced choice."

For many patients, the choice came too late to improve comfort or quality of life in the last months of life. A report from the National Hospice and Palliative Care Organization stated that 43 percent of Medicare patients with a terminal diagnosis in 2014 opted for the hospice benefit, using the benefit a median of 17 days.

"We hope to highlight the benefits of hospice and palliative care for patients and physicians," Alison Ruehl, president of SSM Health at Home, said of the Care Choices program. "Additionally, we hope to demonstrate to CMS that hospice can be expanded further to provide a better quality of life and improved patient experience while lowering the total cost of care." 

Small studies, such as the one conducted by the Hawaii Medical Service Association, a Blue Cross and Blue Shield licensee, in which patients received concurrent curative and palliative treatments, have reported fewer days in acute care and increased patient satisfaction. The HMSA study also found that of 70 Medicare Advantage cancer patients receiving home-based palliative and simultaneous curative care, about 10 percent died in a hospital in 2014. This compares to the 23 percent of people using the Medicare hospice benefit nationally. Most people prefer to die at home. Patients in the Hawaiian study also reported a better quality of life while receiving palliative care services.

Apples and oranges
The benefit under the Care Choices Model is a fraction of the standard Medicare hospice benefit. The maximum reimbursement rate for the Care Choices Model is $400 per patient per month. Medicare's hospice reimbursement is about $4,800 per patient per month. The pilot program will provide patient and family education, case management by a nurse and help for patients and families in setting goals for treatment — most of these services will be provided by phone. In the standard Medicare hospice model many services are provided face-to-face with hospice team members, commonly in a nursing home or at home.

"So there's no question that the richness and complexity and resources that the standard Medicare hospice benefit provides will not be available," Meier said, adding that for $400 a month, "you can't provide a whole lot of in-person visits."

Patients who enroll in Care Choices remain under the primary supervision of the physician providing curative care, so Medicare will continue to reimburse through Parts A, B and D for physician services, physical or occupational therapy, speech language pathology services, drugs for the management of pain or other symptoms from the terminal illness or related conditions, medical equipment, ambulance and short-term inpatient care for pain or symptom management.

Care Choices provides a registered nurse as care coordinator for supportive services that wrap around offerings from the supervising physician. Those palliative care services include counseling, family support, access to in-home respite care and psychosocial assessment. A Care Choices patient conceivably could qualify for all of the services available in the standard Medicare hospice, but the bulk of those services would be reimbursed through Medicare parts A, B and D.

Ruehl noted that the five-year project is designed to discern which palliative services prove most effective while a patient continues to receive curative care.

"It is not clear yet exactly how much service CMS expects patients will need or receive under this model," Ruehl said.  "The pilot is expected to provide feedback to CMS as we learn together."

Screening participants
The qualifications for the program are restrictive. A patient has to be insured by Medicare or be dually eligible for Medicare and Medicaid coverage and be diagnosed with advanced cancer, chronic obstructive pulmonary disease, congestive heart failure or AIDS with a prognosis of six months or less to live. He or she also has to have been hospitalized at least twice and had three office visits with the referring provider in the previous 12 months. The patient also cannot use the standard Medicare hospice benefit for 30 days before participating in the Care Choices Model.

SSM Health at Home could enroll about 1,000 patients in the Care Choices Model over five years through its home-based care service offices in St. Louis, St. Charles, Jefferson City, and Maryville, Mo., and Madison, Wis. But because of the restrictions, Ruehl said, "We anticipate very few people qualifying. This will become clear during the pilot, and we will provide feedback to CMS."

Despite the limitations and unknowns, Ruehl said she hopes that the Care Choices Model will provide patients and their families improved access to end-of-life care and encourage them to be actively involved in making care decisions.

Meier added: "I wish it would show that because of an added layer of support provided by the Medicare Care Choices Model, people were able to remain in their own homes and avoid hospitals, that they report better quality of life and better family outcomes and that they were more likely to spend the rest of their lives where they want to be."


Savings are a source of debate

Among the goals of the Medicare Care Choices Model is saving money. Aetna's study of its Compassionate Care program, which offers case management by a nurse who coordinates palliative and curative treatments for terminally ill patients, estimated a 22 percent reduction in overall costs for care from enrollment to the patient's death versus costs for patients who chose between Medicare curative or hospice services.

But experts are divided on whether Care Choices will save Medicare money. Dr. Diane Meier, directs the Center to Advance Palliative Care, a national organization based in New York City. She provided a hypothetical that illustrates how cost savings due to limited services offered in the Care Choices Model could quickly be offset.

"If you've got someone having a crisis at 3 in the morning and they call the Medicare Care Choices number and they don't hear back for 45 minutes, they're probably going to call 911," Meier said, which would trigger a series of expensive services: ambulance, emergency department and inpatient treatment.

Kathleen Benton, director of clinical ethics at St. Joseph's/Candler Health System in Savannah, Ga., noted that the key to keeping costs low and the quality of the program high is "choosing the right professionals with good communication skills who can engage the patient in planning his or her care. … Hospice professionals are some of the best at having those kinds of conversations. "


Copyright © 2016 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2016 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.