Some advanced cancer patients will not have to choose between curative therapy and hospice care after the Centers for Medicare & Medicaid Services (CMS) launches the Medicare Care Choices Model on Jan. 1.
Care Choices is a five-year program in which CMS will explore whether certain Medicare patients with terminal illnesses would be well served by the opportunity to receive hospice services while they are also receiving chemotherapy or other treatment.
Leanne Burrack, RN, Executive Director of Hospice for UnityPoint at Home in three Midwestern states, said she believes the program will make it easier for patients to accept the hospice services that could make their lives easier as their disease progresses.
“They don’t have to let go of one rope to grab onto another rope,” she said. “They can hold onto both ropes until they are comfortable.”
Similarly, Diane Meier, MD, Director of the Center to Advance Palliative Care, said she hopes the Care Choices Model will contribute to a cultural change that makes concurrent palliative care the standard of care for people with serious illnesses.
“It will hopefully demonstrate to oncologists that they can continue their specialty-level care for their patients in partnership with a team that will focus on things that are outside the oncologist’s bailiwick—like family caregiver exhaustion, social issues, family conflict, and intractable constipation. These are things that oncologists have neither the training nor the time to address, yet I think every oncologist would agree that these are incredibly important issues in terms of optimizing their patients’ health and wellbeing.”
Multiple Choices for Patients
The Care Choices program is not identified as a pilot or a demonstration, but rather a five-year program that will allow Medicare to evaluate whether eligible patients will embrace the chance to receive hospice services.
The program seeks to address the fact that only 47 percent of Medicare patients and 42 percent of dual eligibles (patients eligible for both Medicare and Medicaid) who qualify for hospice services actually enroll—and most of those for only a short period of time very near the end of life. The government believes that this is because, under the current rules for hospice, patients must choose between the palliative services available via hospice and potentially curative therapy.
Care Choices targets patients who live at home and who are struggling, as evidenced by the requirement that they have had at least two hospitalizations related to their terminal illness in the previous year.
Under this program, physician services, medications, medical equipment, short-term inpatient care for pain or symptom management, and some services, such as physical or occupational therapy, will be paid for through the traditional Medicare fee-for-service system. Participating hospices will receive a per-beneficiary, per-month fee for nursing, social work, bath aide/homemaker services, chaplain, and respite care services.
Although the monthly fee is small—$200 a month for patients enrolled in the program less than 15 days; $400 a month for those enrolled 15 days or longer—hospice providers went wild for the idea when it was first announced.
CMS originally planned to accept 30 hospices and enroll up to 30,000 patients over a three-year period. But because of the intense interest, the program was expanded to include more than 140 hospice programs serving up to 150,000 patients over five years.
About half will start on Jan. 1, 2016, and the rest will begin Jan. 1, 2018.
Longer Periods of Hospice Care
“The reason we are so excited to be part of this program is because our referrals to hospice are coming so late,” Burrack said. “That means we are only able to support that patient and family for a very short length of time.”
UnityPoint Health, a large health system serving Iowa, Illinois, and Wisconsin, provides inpatient palliative care and hospice services in all its markets. Three UnityPoint Hospice locations were chosen to participate in the Medicare Care Choices program; the Fort Dodge, Iowa, location will begin Jan. 1, while the other two will join in Phase 2, in 2018.
Burrack noted that the median length of stay at UnityPoint’s hospice-at-home programs currently ranges from three to 11 days—much shorter than the national median of 21 days. Similarly, the average length of stay at UnityPoint hospices is 45 to 50 days, compared with a national average of more than 75 days.
When patients enroll in hospice just a few days before death, the experience is likely to be less than optimal for all parties. Patients and their family caregivers must deal with the intake process, receipt of hospice equipment and supplies, and other logistics but they receive the support that hospice offers for only a very brief period.
“Not only do the patients and families not benefit from those services over an extended amount of time, but the staff caring for the patient and family members are put in a very complex and possibly crisis-management type situation,” said Monique Reese, DNP, Chief Clinical Officer of UnityPoint Clinic and UnityPoint at Home.
Patients who receive concurrent care through the Care Choices program will be able to experience the benefits of hospice support. And when it is appropriate for them to consider discontinuing curative therapy and moving to the traditional hospice benefit, they are likely to be better informed about the services they can expect.
“We want to help them understand that electing the hospice benefit does not mean they are actively dying,” Burrack said. “We really do focus on living and how we can support them to live their best life while the disease is progressing.”
That means keeping patients out of the hospital, if possible. Patients become eligible for the Care Choices program only if they have two hospitalizations in a year, which suggests they are struggling with symptoms related to their diagnosis or the side effects of treatments. Chad Tuttle, President of Spectrum Health Continuing Care, said he believes that offering hospice services to patients undergoing treatment will prove to Medicare that concurrent care improves patients’ well-being while keeping them out of an inpatient bed.
“Our hope is that if this program is successful, Medicare will look at the results and say, ‘This is the strategy that should be brought in earlier, even before that second acute hospitalization,’” he said.
Improving Clinicians’ Comfort Level
One reason for the low hospice use among patients who qualify for the services is that physicians do not refer them until shortly before death. In a study that focused on palliative care, rather than hospice specifically, Yael Schenker, MD, MAS, a palliative care specialist at the University of Pittsburgh Cancer Institute (UPCI) in Pennsylvania and her colleagues shed some light as to why (OT 2/25/14 issue).
The research team interviewed 74 oncologists at UPCI, the University of California San Francisco Helen Diller Comprehensive Cancer Center, and Mount Sinai Tisch Cancer Institute, all three of which have comprehensive palliative care clinics. While some survey respondents did consider palliative care to be complementary to therapy, the results did uncover three physician barriers to referrals: a belief that palliative care is an alternative to and incompatible with cancer therapy; a belief that providing palliative care is the oncologist’s responsibility; and lack of awareness about palliative care services.
A significant minority of oncologists in that study (22 of 74) viewed palliative care as an alternative to cancer therapy. Writing in the Journal of Oncology Practice (2014;10: e37-e44), Schenker and her coauthors quoted one oncologist who said “If a patient is a chemotherapy candidate, they’re not a palliative care candidate.”
Lisa VanderWel, Senior Administrator at Spectrum Health Hospice, said engaging physicians is a key component of her plan for participating in the Medicare Care Choices program. Spectrum Health Hospice, part of the Spectrum Health system, is one of 10 hospices in Michigan chosen to participate in the program.
“We are definitely going to go in front of our physician groups to educate them on this program,” she said. “We want the physicians to know what they can expect us to do for their patients at home. Communication and partnership are what’s really going to give patients the support they need.”
‘Not a Tipping Point’
Meier said she sees the Care Choices program as a good idea for increasing patients’ access to palliative care and hospice services, but not one that will bring about a tipping point.
“It’s just one lever among many that need to be applied, but by itself, it will certainly not be enough,” she said. “What we are seeing is a need for a culture change, not only in oncology but also in many specialties that care for people with serious complex illnesses.”
New Value-Based Payment Incentives
Meier advocates for new value-based payment incentives that encourage health care providers to engage patients in discussions about what to expect in the future and what matters most to them if their illness progresses; greater support for patients in their homes; and changes in medical education.
“The training of clinicians has been totally focused on the latest disease treatment,” she said. “It really has not included--and does not include even today--helping specialists such as oncologists to understand that there’s a lot more to the role of being a patient’s doctor than administering chemo or radiation or recommending surgery.”
Until now, Medicare’s payment policy has forced patients to choose either hospice care without access to their cancer physician or curative therapy without access to hospice services. Severing the patient/physician relationship when the patient is very ill does not feel right to either the patient or the physician.
“I’ve had many patients say, ‘I don’t understand why my oncologist is not in touch with me.’ And the oncologist says to me, ‘I can’t do anything for them; they’re on hospice,” Meier said. “And that’s sort of tragic because it trivializes the doctor-patient relationship to one of administering chemotherapy.”
VanderWel, at Spectrum Health Hospice, said she expects that physicians will embrace Medicare Care Choices when it becomes available: “I’m hopeful that they’re going to find this as quite a relief because they can continue with their treatment plan for their patients and we can provide patients the care that they need at home.”
The Medicare Care Choices Model is available for patients who:
● Have been enrolled in traditional Medicare for at least two years--patients who participate in Medicare Advantage or other managed care plan are not eligible;
● Have a diagnosis for terminal cancer, chronic obstructive pulmonary disease, congestive heart failure, or HIV/AIDS and meet the hospice definition of terminal illness;
● Have had at least two hospitalizations in the past year related to the qualifying diagnosis;
● Are expected to live six months or less;
● Live in a traditional home;
● Have not received hospice benefits in the past month; and
● Live in an area served by a hospice participating in the new program.