Hospice as a target for savings

Politico has a story today about the Medicare hospice benefit taking cuts in the ACA and in the sequester if the Super Committee does not produce an alternative deal. There are lots of parts to this story and I have blogged on many of these topics in the past:

• Palliative care, which is related, but not the same as hospice is key if we are to improve quality while reducing costs.
• A study of early palliative care in stage IV lung cancer showed decreased costs and improved quality of life. A project team here at Duke has received a grant to replicate this study in CHF.
• Very long lengths of hospice use give rise to worries about inappropriate use, and are made more worrying to some because for profit providers are more likely to have long stays. Here is a link to the MEDPAC recommendations about hospice payment changes.
• Lack of a straightforward LTC financing approach bleeds over into and complicates Medicare hospice and home health policy.
• There is a great deal of interest in profit margins, especially of for profit hospices due to length of stay. However, very short length of stay likely signify quality problems or patients not receiving all they might from hospice.
• I have done work with colleagues at Duke that shows that hospice reduces Medicare costs compared to what they would have been. However, this analysis leaves out quality, which must be known to fully evaluate the appropriateness of such care.
• I am P.I. of a grant from HCFO, an initiative of the Robert Wood Johnson Foundation, titled “Identifying the Use, Cost and Quality Tradeoff in the Medicare Hospice Benefit” and we hope to have initial papers out soon. The main goal is to look at use, cost and quality simultaneously, which is the key to determining appropriateness.
• It is easy to get lost in the variety of issues in hospice policy, but here are the key issues as I see them.

• Medicare hospice policy needs to be updated because the basic regulations are unchanged since 1983. In particular, the language of having to ‘unelect curative care’ in order to access hospice makes no sense. If we could ‘cure’ the disease in question we would. What they meant was you have to unelect ‘the default in the health care system which is aggressive care.’ We need to modernize the language.
• We need to get straight the distinction between hospice and non-hospice palliative care. Non-hospice palliative care could be viewed as care that addresses symptoms regardless of prognosis. Hospice is a subset of palliative care that is for persons who are believed to be in the last 6 months of their life.
• We need to move toward concurrent palliative care, which means addressing symptoms before a person is viewed as ‘dying’, but do this in a way so that CMS doesn’t think that what we are actually doing is developing a back door long term care benefit. This is a key issue since ~90% of hospice paid for by Medicare is provided to people in their homes.
• We need to determine the linkage between use, cost and quality of all of these services. Most research has looked at use and cost, or use and quality of hospice or palliative care. You need to know all three to be able to evaluate the appropriateness of care or to determine if it is ‘working’ or ‘worth it.’ I have two research studies underway on this, and hope to have preliminary results in the Fall.
• Note that for a variety of reasons, including the fact that the introduction of the hospice benefit in the early-1980s was sold at least partly on the basis that it would not increase overall Medicare costs and so would ‘save money’, hospice care in particular has been evaluated differently from just about everything else that Medicare pays for. For example, no one asks if a new chemotherapy, or a left-ventrical assistive device improves quality AND SAVES MONEY. The question is does it improve QOL and/or extend life and how much does it cost to do so. There is nothing else that Medicare purchases that I can think of that is expected to provide benefits AND SAVE MONEY. I realize I have helped to drive this expectation by publishing papers such as this.
• All of this has to be done in the current political environment in which when in doubt, politicians accuse their opponents of wanting to ration care, kill my grandmother, etc. Shocking as it may seem, this does not help us develop better policy.