CMS to test con­cur­rent cov­er­age of hos­pice and cu­ra­tive care

Modern Healthcare - - NEWS - By Me­lanie Evans

Ter­mi­nally ill pa­tients regularly call Dr. Christina Puchalski hours or days af­ter tough con­ver­sa­tions about the lack of re­main­ing treat­ment op­tions for fight­ing their dis­eases.

“Some peo­ple want to con­tinue with cu­ra­tive treat­ment un­til it’s re­ally ob­vi­ous it’s not work­ing,” said Puchalski, a pal­lia­tive-care spe­cial­ist and di­rec­tor of the Ge­orge Washington Univer­sity In­sti­tute for Spir­i­tu­al­ity and Health. “Some say, ‘I re­ally need to try it all.’ ”

Up to now, that de­sire to con­tinue seek­ing a cure has forced pa­tients and their fam­i­lies to go with­out Medi­care-paid hos­pice care. Medi­care pol­icy has been that the pro­gram won’t pay for hos­pice—which in­cludes pain man­age­ment, nurs­ing care, coun­sel­ing, and respite care in a hos­pice fa­cil­ity or at home—un­til pa­tients stop treat­ment to slow or cure their dis­ease, such as chemo­ther­apy or ra­di­a­tion ther­apy.

For pa­tients, the “dance” of hear­ing the news that they have a ter­mi­nal dis­ease and ac­cept­ing it starts with the di­ag­no­sis and of­ten con­tin­ues un­til the Medi­care cov­er­age pol­icy forces the is­sue. “If you’re talk­ing about hos­pice, the dance has to end,” Puchalski said. “The pa­tient has a very hard choice.”

Now that one-or-the-other pol­icy, which has been crit­i­cized for not rec­og­niz­ing the emo­tional re­al­ity of dy­ing, will be re­laxed for some Medi­care pa­tients un­der an experiment to see whether con­cur­rent cov­er­age of cu­ra­tive and hos­pice care re­duces costs and in­creases the qual­ity of care.

The CMS experiment, sched­uled to start in Jan­uary and run through 2020, will al­low about 140 hos­pices across the U.S. to care for pa­tients who may also con­tinue cu­ra­tive treat­ment with the po­ten­tial to slow their dis­ease and pro­long life. The test, known as the Medi­care Care Choices Model, will in­clude as many as 150,000 pa­tients and was launched un­der the Af­ford­able Care Act.

The ini­tia­tive will roll out in two phases with the first hos­pices en­ter­ing in Jan­uary and a sec­ond wave to be­gin in Jan­uary 2018. Con­di­tions qual­i­fy­ing pa­tients for par­tic­i­pa­tion in­clude can­cer, con­ges­tive heart fail­ure, chronic ob­struc­tive pul­monary dis­ease and HIV/AIDS. So many hos­pice providers ex­pressed an in­ter­est in par­tic­i­pat­ing that the CMS in­creased the pos­si­ble ros­ter to 140 hos­pice providers from the orig­i­nal limit of 30.

The way the pro­gram is struc­tured, with some hos­pices start­ing the pro­gram in 2016 and the rest start­ing two years later, will al­low the CMS to com­pare out­comes be­tween the two groups and a third group of hos­pices not par­tic­i­pat­ing. Dr. Pa­trick Con­way, the CMS’ chief med­i­cal of­fi­cer, told the New York Times that the de­sign will make it pos­si­ble to do a more ro­bust eval­u­a­tion of the pro­gram and de­ter­mine whether it should be ex­panded to all Medi­care ben­e­fi­cia­ries and hos­pices.

Ex­perts say the new pro­gram rec­og­nizes that lines in­creas­ingly have blurred be­tween cu­ra­tive and pal­lia­tive treat­ments. For in­stance, blood trans­fu­sions may pre­vent fa­tigue for bone-mar­row dis­ease pa­tients so they can bet­ter en­joy their re­main­ing days, said Dr. Steven Op­pen­heim, med­i­cal di­rec­tor of pal­lia­tive medicine at the Ban­ner Thun­der­bird Med­i­cal Cen­ter in Glendale, Ariz. Un­der the ex­per­i­men­tal pro­gram, pa­tients will be able to con­tinue those trans­fu­sions while re­ceiv­ing the hos­pice ben­e­fit.

The hope is that the new ini­tia­tive will en­cour­age a higher per­cent­age of dy­ing pa­tients to take ad­van­tage of hos­pice and that doc­tors will re­fer them ear­lier. Last year, the CMS said only 44% of Medi­care pa­tients used the hos­pice ben­e­fit at the end of life. Most use it for only a short pe­riod of time. Some re­search shows that African-Amer­i­cans and other mi­nori­ties are even less likely to use hos­pice ser­vices.

Un­der Medi­care rules, doc­tors may re­fer pa­tients for hos­pice cov­er­age when they have a prog­no­sis of six months or less to live. But in 2013, Medi­care pa­tients’ me­dian length of stay in a hos­pice was only 17 days. Among Medi­care can­cer pa­tients who en­ter hos­pice, half do so with less than three weeks to live, and 1 out of 10 en­ters hos­pice within three days of dy­ing. On­col­o­gists con­sider such brief use of hos­pice a mea­sure of poor qual­ity of care.

There’s broad con­sen­sus that hos­pice care im­proves qual­ity of care for

Ex­perts say the new pro­gram rec­og­nizes that lines in­creas­ingly have blurred be­tween cu­ra­tive and pal­lia­tive treat­ments.

dy­ing pa­tients and their fam­i­lies. A study pub­lished in 2010 in the New Eng­land Jour­nal of Medicine found that among pa­tients with metastatic non­s­mall-cell lung can­cer, early pal­lia­tive care led to sig­nif­i­cant im­prove­ments in qual­ity of life and mood com­pared with pa­tients re­ceiv­ing stan­dard care. The pa­tients re­ceiv­ing the early pal­lia­tive care had longer sur­vival de­spite re­ceiv­ing less ag­gres­sive care at the end of life.

Whether the Care Choices Model will save money is another ques­tion. Medi­care spend­ing on hos­pice in­creased about 50% from $10.1 bil­lion in 2007 to $15.1 bil­lion in 2013, ac­cord­ing to the CMS. There have been in­creas­ing con­cerns about hos­pice costs, with some re­search show­ing that the grow­ing dom­i­nance of for­profit providers has been as­so­ci­ated with ris­ing uti­liza­tion and costs.

The new pro­gram may save money by help­ing pa­tients avoid emer­gency depart­ment vis­its and hos­pi­tal­iza­tions when they ex­pe­ri­ence med­i­cal crises, said Melissa Aldridge, an as­so­ciate pro­fes­sor of geri­atrics and pal­lia­tive medicine at the Ic­ahn School of Medicine at Mount Si­nai, who has stud­ied dif­fer­ences in en­roll­ment rates be­tween for-profit and not-for-profit hos­pice providers.

Hos­pice providers can work more closely with pa­tients and care­givers to pre­vent those crises, she said.

Un­der the ini­tia­tive, hos­pices, in­stead of get­ting a per diem pay­ment, will re­ceive a Medi­care monthly pay­ment of $200 to $400 per pa­tient for any hos­pice care that pa­tients need. Mean­while, other providers can still bill Medi­care for cu­ra­tive ser­vices.

The model also will al­low pa­tients to ac­cess al­ter­na­tives to med­i­cal in­ter­ven­tion or drugs— such as mas­sage ther­apy for pain—that Medi­care won’t oth­er­wise pay for, said Pamela Halvor­son, pres­i­dent of Fairview Home Care & Hos­pice in Min­neapo­lis.

Pa­tient pref­er­ences aren’t the only rea­son for un­der­use of hos­pice ser­vices. Medi­care typ­i­cally pays hos­pices a per diem rate, which has also been cited as a fac­tor. A study pub­lished in Health Af­fairs found that 3 out of 4 hos­pices sur­veyed in 2008 and 2009 re­ported poli­cies that would ex­clude com­plex pa­tients who need trans­fu­sions, pal­lia­tive chemo­ther­apy, tube feed­ing and other costly ser­vices.

The Care Choices Model will al­low pa­tients to en­ter hos­pice be­fore they fully come to terms with their ter­mi­nal prog­no­sis, ex­perts say. For se­ri­ously ill pa­tients, the choice of when to stop treat­ment can be murky. How pa­tients come to ac­cept dy­ing is pro­foundly per­sonal. A prog­no­sis may be over­shad­owed by re­li­gious be­liefs, emo­tional tur­moil or how well some­one feels, and fam­ily mem­bers’ views and de­sires, re­gard­less of the pa­tient’s de­te­ri­o­rat­ing health.

Re­cent stud­ies high­light how widely pa­tients’ per­cep­tions of their health can de­vi­ate from the med­i­cal facts. “Some­times those can be re­ally, re­ally far apart,” said Rafael Romo, a nurse and qual­ity scholar fel­low at the San Fran­cisco Vet­er­ans Af­fairs Med­i­cal Cen­ter.

He cited a 2011 ran­dom­ized con­trolled trial of pal­lia­tive care com­bined with can­cer treat­ment ver­sus only can­cer treat­ment. Half the pa­tients re­ported be­ing “rel­a­tively healthy” at the start and only 13% re­ported a ter­mi­nal ill­ness, de­spite hav­ing metastatic non­s­mall-cell lung can­cer, which has an es­ti­mated prog­no­sis of one year from when pa­tients are di­ag­nosed.

A sep­a­rate anal­y­sis of those pa­tients found two-thirds of those same pa­tients re­ported their goal for care was a cure. One-third re­ported their can­cer could be cured, de­spite a di­ag­no­sis with the like­li­hood they would not sur­vive more than a year.

Romo said the Medi­care Care Choices Model will al­low pa­tients “time to ad­just” with sup­port from hos­pice providers, who in­clude so­cial work­ers, clergy and be­reave­ment coun­selors. Even for pa­tients who don’t be­lieve they will die, ad­di­tional time al­lows for re­peated con­ver­sa­tions to help pa­tients iden­tify their goals for med­i­cal in­ter­ven­tion and more clearly un­der­stand their con­di­tion. “They’ll be able to see their health in a more re­al­is­tic way,” he said.

Re­search pub­lished this month in JAMA On­col­ogy found chemo­ther­apy did not im­prove the qual­ity of life for pa­tients in their fi­nal days. In­deed, for those pa­tients least de­bil­i­tated by can­cer, chemo­ther­apy wors­ened their qual­ity of life.

The new model will give pa­tients and their fam­i­lies more time to build trust with the so­cial work­ers, nurses and doc­tors on the hos­pice team, Ban­ner’s Op­pen­heim said. That trust can help with ac­cep­tance of the dy­ing process and im­prove the qual­ity of the pa­tient’s re­main­ing days, he added.

“Hos­pice re­ally has a lot more to of­fer pa­tients and fam­i­lies” than can be ex­pe­ri­enced in two weeks, which is the me­dian time pa­tients spend in hos­pice, he said. “It’s a rush job at the end.”

Ex­perts say the pro­gram rec­og­nizes that lines have blurred be­tween cu­ra­tive and pal­lia­tive treat­ments. For in­stance, blood trans­fu­sions may pre­vent fa­tigue for bone-mar­row dis­ease pa­tients so they can bet­ter en­joy their re­main­ing days, said Dr. Steven Op­pen­heim, med­i­cal di­rec­tor of pal­lia­tive medicine at Ban­ner Thun­der­bird Med­i­cal Cen­ter.

The new pro­gram may save money by help­ing pa­tients avoid emer­gency depart­ment vis­its and hos­pi­tal­iza­tions when they ex­pe­ri­ence med­i­cal crises, ac­cord­ing to Melissa Aldridge, as­so­ciate pro­fes­sor of geri­atrics and pal­lia­tive medicine at the Ic­ahn School of Medicine at Mount Si­nai.

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