Feature

Larry Beresford

At the end of this year, the Medicare Care Choices Model (MCCM) demonstration project will wrap up its examination of a concurrent care model for covering hospice-type services while permitting enrolled patients to simultaneously receive additional medical services, including curative treatments, from other healthcare providers. Is this government demo the future of hospice care, and what would that mean for hospice practitioners?

Described as one of only six among the dozens of demonstration projects launched by the federal Centers for Medicare & Medicaid Innovation (CMMI) to show statistically significant success, such as savings for the Medicare program, MCCM reduced Medicare expenditures by $26 million—or 25%—for 3,600 enrollees who died in the program between 2016 and 2019. These patients had fewer acute hospitalizations than matched nonparticipants, fewer emergency department visits, and fewer stays in the intensive care unit (ICU). Eighty-four percent eventually opted for hospice care, enrolling an average of 1 week earlier than those not in the program. The quality of care was reported as being better, and caregivers reported high satisfaction with the care their loved ones received, both under MCCM and in their transition to the Medicare hospice benefit.¹

At the same time, enrollment in the demo was challenging for participating hospices, and fewer patients than anticipated were enrolled. Forty-five percent of those referred were found not to meet enrollment requirements, which include criteria such as Medicare fee-for-service coverage; presence in a traditional home setting; hospice eligibility including a 6-month terminal prognosis; and a diagnosis of cancer, congestive heart failure, COPD, or HIV/AIDS. Only Medicare-certified hospices could participate, with as many as 142 joining at some point, although many dropped out along the way. By June of 2020, only 82 remained in the program.

Some felt the reimbursement of $400 per participant per month was not sufficient to make them want to pursue enrollees, although this payment was only intended to cover portions of the hospice's services, such as nurse, social worker, aide, and chaplain visits and care coordination/case management—but not many of the services hospices are required to provide under the Medicare hospice benefit, such as medications, equipment, and supplies. Government data reporting requirements, though the lifeblood of a successful demo, were another significant burden on participating hospices.

As enrollment in MCCM winds down, participating hospices and policy advocates are asking what's next. The project's success on key metrics would seem to point toward a form of coverage for hospice care that doesn't impose the "terrible choice" on seriously ill Medicare patients—who today must elect to give up conventional medical treatments aimed at cure in order to qualify for the comprehensive, interdisciplinary benefit of hospice care, aimed at relieving the pain, suffering, and symptoms of advanced illness.

It also highlights the need to find a way for covering community-based palliative care services that could be offered earlier in the disease trajectory than a hospice referral, helping patients cope with the symptoms of serious illness well in advance of when they might choose or qualify for a full hospice benefit.

But what would a more widely available concurrent hospice model or a complementary community-based palliative care benefit look like? How might they be coordinated? Who should be allowed to provide these services, and what should they be paid for doing so? When might this happen, and what are the implications for the long-established business model of hospice care in America, defined in the 1982 legislation that created the Medicare hospice benefit, and for the 4,639 hospices whose current business is strongly tied to the Medicare benefit even as many explore palliative care service lines?

"We are excited by the results from this demonstration," said Annie Acs, MPH, senior director for health policy & innovation at the National Hospice and Palliative Care Organization (NHPCO). "I think this is definitely a pathway to concurrent care and it shows that concurrent care is an important model. For many seriously ill patients, having to make a choice between conventional care and hospice care is a barrier to hospice access." That is particularly true for people of color, who historically have been underserved on hospice caseloads, she added.

AAHPM and the other 12 organizational members of the National Coalition for Hospice and Palliative Care, as well as other stakeholders, would like to see CMMI expand on the MCCM demo experience by testing a community-based palliative care model. NHPCO calls this new option a "second generation" of the MCCM demo, with eligibility expanded to cover more conditions, more benefits, and other categories of providers and with payments increased from $400 to $600 per enrollee per month.

"We are in touch with the MCCM research team and have shared the need for this model," Acs said. "They have said publicly that they are hopeful to move forward with a demo in the palliative care space, but we don't have a timeline for that."

CMMI has the authority to launch such a demo, although a permanent benefit for either concurrent hospice care or community-based palliative care ultimately would require an act of Congress, she said. "We stand ready to support CMMI to implement this and to work out the details."

Voices From the Field

For some participating hospices, the government's demo project involved a lot of work, including reporting requirements, barriers to access, and a monthly stipend that was only worth about 2 days on routine hospice care.

"This is my 32nd year in hospice, and we've been talking about hospice concurrent care for 20 years," said Todd Coté, MD, chief medical officer at Bluegrass Navigators, a hospice and palliative care organization based in Lexington, KY. "We were perhaps naively excited about the demo in that context. What we found was that when physicians kept referring us patients who weren't eligible for MCCM, they would get upset," Coté said. "We don't have to belabor the demo's regulations, but we wished they could have opened it up to be more inclusive."

He said he was excited to be working under a per-member-per-month payment structure, "but we never could maintain census. We were able to care for people who fell into the gaps, and many ended up on hospice care who might never have reached hospice otherwise."

According to Coté, the MCCM model is even more timely today than it was when first announced 7 years ago, especially for patients who are at home and falling through the cracks. He believes there is a recurring need for patients who want to try one more therapy yet are terribly, and likely terminally, ill.

For such patients, and for those who find it increasingly difficult to see their doctors in person, Bluegrass Navigators is experimenting with an approach that triangulates hospice with palliative care and primary medical care at home. "Our model is still grassroots—with palliative care consultations and hospice-like support from an interdisciplinary team. This is hard to do. These are high-need patients," he said.

For hospice and palliative care physician Christine Khandelwal, DO, vice president of education for Transitions LifeCare, a hospice in Raleigh, NC, the opportunities to work through and learn how to provide a new kind of value-based benefit proved more important than the demo's problems. "The MCCM model is about expanding the population we serve and actively getting paid to support this kind of programming. It felt good to offer options for those who need a little more support. It helps us to stay ahead of the game, and keeps us at the table," she said.

Transitions LifeCare intends to continue experimenting with palliative care and to seek alternative funding from payers, grants, and value-based purchasing models. "I'm optimistic that we can drive this," Khandelwal said. "We were hoping MCCM might be the bridge to help us better meet the needs of underserved populations—as well as of the self-selected group that just doesn't want hospice care, although they may select it later." There are still a lot of gray areas, she added, including the question of which treatments are palliative and improve quality of life—versus just prolonging life—and what allows for a more comfortable death?

Laura Patel, Khandelwal's colleague and chief medical officer of Transitions LifeCare, called MCCM "our first foray into value-based payment models—or at least something approaching that. It was very valuable to us to grow those skills. It was an investment for us, even though we didn't necessarily break even with the MCCM monthly rates," she said.

MCCM provided a simple framework with which many types of community organizations across the country could support care for seriously ill individuals, Patel said: "If this framework were expanded to include more diagnoses, longer prognoses, and slightly increased rates, it could be rolled out quickly to give more patients the care they need. I think the MCCM program showed great results in terms of cost savings, reduced utilization at end of life, and high levels of satisfaction. We need to look at what the results might be if access were expanded."

Other Perspectives on Concurrent Care

Concurrent care—allowing patients to choose the comprehensive support of hospice teams without having to give up other medical treatments—has been part of the debate about the future of hospice for a long time. Two other approaches to end-of-life care that could offer some insights on the concurrent model are pediatric hospice care and the hospice and palliative care model in the Veterans Affairs (VA) health system.

It has long been recognized in the hospice field that requiring the parents of children with life-threatening illnesses to choose between disease-focused curative therapy and hospice would mean that most would forgo the support hospice could offer. Section 2303 of the 2010 Accountable Care Act, "Concurrent Care for Children," created a concurrent model of care under Medicaid and the Children's Health Insurance Program and required state Medicaid programs to pay for both curative and hospice services for qualifying children.

"In a perfect world, at the time of a serious illness diagnosis, both palliative care and life-prolonging interventions are delivered in parallel. Then, once a child reaches a less-than-6-month prognosis, pediatric concurrent care hospice services are integrated within the care plan alongside life-prolonging interventions, meaning that pediatric families are not forced to choose between comfort-promoting hospice interventions and life-prolonging interventions," said Alexis Morvant, MD, assistant professor of clinical pediatrics at Louisiana State University School of Medicine and medical director of pediatric palliative care at Children's Hospital New Orleans.

"We didn't have a formal demo for this," added Lisa C. Lindley, PhD RN FAAN FPCH, associate professor of nursing at the University of Tennessee Knoxville (UTK). "We've had informal demos that informed the legislation. The issue of a 6-months-or-less prognosis is still controversial in the pediatric care community. We're still trying to learn what concurrent care means, although we know the population we see. These kids are very ill with multiple comorbidities. We know some will use everything Medicaid has to offer and others just see their primary care providers."

Research has been collected by The Pediatric End-of-Life (PedEOL) Care Group, housed at UTK, under a 4-year award of $1.5 million from the National Institute of Nursing Research to study the "Effectiveness of Concurrent Care to Improve Pediatric and Family Outcomes at End of Life."

Preliminary results suggest that hospices lose a little less money per patient on those who receive concurrent care, with outcomes such as improved continuity, fewer hospice discharges, and improved engagement by families, although there were mixed results in symptom management, Lindley said. Care coordination—and who is doing it—is a big deal.

The Veterans Health Administration has a national policy for hospice and palliative care, emphasizing a continuum of care without forcing a terrible choice for veterans. The VA mandates that if a veteran is at high risk for a life-threatening event in the next 2 years, a VA primary care physician or specialist must initiate a goals-of-care conversation.

Every VA medical center has an interdisciplinary palliative care team, and many have palliative care units. "But VA staff don't go into veterans' homes, typically, except for home-based primary care," said Scott T. Shreve, DO, the VA's national director of palliative and hospice care. Hospice care in the home typically is provided by local hospices, with which the VA is able to contract for services and, in some cases, pay for the hospice benefit.

"We are going to refer appropriate veterans to community hospice programs," he said. For a long time, enshrined in VA policy, hospice and palliative care have represented a continuum of comfort-oriented services. "We try to avoid duplication of services, but if the veteran can benefit from palliative radiation or chemotherapy and the VA can be brought in as a partner, that just makes sense to me," Shreve said. Mor and colleagues found in 2019 that increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.²

Complications can arise if a VA patient receiving the Medicare hospice benefit from a community hospice also gets supplementary services, such as palliative radiation, from a VA medical center, and the hospice, fearing accusations of double dipping, questions whether the patient is still eligible for the Medicare hospice benefit. Medicare regulations require the hospice to "own" the enrolled patient's plan of care, but when veterans elect hospice care, they don't give up their VA benefits, Shreve explained.

Where Do We Go From Here?

"Without something like MCCM, there is a gap in care for seriously ill patients before they reach hospice," said Lori Bishop, NHPCO's vice president of palliative and advanced care. "What is the next something to fill that gap?" Existing palliative care models typically don't cover medications, supplies, or durable medical equipment. "When you get to hospice care, if you need a hospital bed in the home, boom, you've got it. Outside of hospice, these things are not easy to obtain," she said.

"We don't fix noncurable diseases, and seriously ill patients continue to have a need for management of their disease," Bishop said. "It's not just about medical needs. We know that social determinants of health can have a greater impact on their health needs"—which highlights the need for an interdisciplinary model of care.

Today, there is no model in Medicare that provides for reimbursement of this kind of care by an interdisciplinary team, just individual services such as physician home visits. "There is an opportunity for a complement of palliative care for seriously ill individuals who aren't terminally ill, in order to help them with symptom management, in close collaboration with their primary care and specialty medical providers for management of their disease," Bishop said.

NHPCO encourages its hospice members to diversify their business model and to look for opportunities to build palliative care services further upstream in the course of an illness. "We've offered a lot of resources including a community-based palliative care certificate program and a playbook to help them understand the basics of assessing need, diversifying reimbursement, and scaling up the model," Bishop said.

Will all of NHPCO's provider members be able to come along on this journey? "There's always an element of wait-and-see," Bishop said. "By offering a further-upstream tier of support, you can start having these conversations with patients earlier, building rapport, and helping them to understand their options."

Many patients at the end of life eventually will need the full complement of treatment, including from other members of the team: spiritual, social work, volunteer, and bereavement. "We don't want to lose that comprehensive hospice benefit but to provide for needed portions of it to be offered further upstream, because it's a beautiful model," Bishop said.

COVID-19 taught us the need to adapt and evolve, Acs added: "We saw that with the wider use of telehealth. We want to encourage our folks to evolve with the rest of the system and, regardless of size, geography, or tax status, to engage in palliative care services further upstream," she said.

"I'm a hospice CMO. I believe in hospice," said Patel. "I don't believe we should tear the hospice benefit apart. It's been a stable, consistent model that has supported so much good care."

Coté, too, intends to keep working on making hospice better: "The public in general still loves hospice, even with the bad press. Other doctors say to us, 'You do such great work.' It's such an affectionate reaction to something people say they don't want."

References

1. Abt Associates. Evaluation of Medicare Care Choices Model—Annual Report 3. https://innovation.cms.gov/data-and-reports/2020/mccm-thirdannrpt. Published October 2020. Accessed June 2020.
2. Mor V, Wagner TH, Levy C, et al. Association of expanded VA hospice care with aggressive care and cost for veterans with advanced lung cancer. JAMA Oncol. 2019 Jun 1;5(6):810–816.

Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.

Read the next article or go to the table of contents.