• 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:

    • 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.
    • Thanks for noticing my POLITICO story — I too have written extensively — very extensively — about palliative care as an alternative to, and part of a continuum with, hospice (athough this article focused on the hospice benefit) Please let me know when your HCFO paper is done, very interested in this.Austin knows where to find me!

      • @Joanne Kenen
        Hey. It was a nice article…as you know, so many inter-related parts to the policy, and then there is the insane politics in this area. I will let you know about results and we may be putting out a working paper version. Doing a simulation of what a u shaped hospice payment would look like per costs, and a paper on primary collected data looking at use, cost and quality of palliative care. Also interesting to think of the degree to which hospice/palliative is or is not a part of LTC. I often give my students an assignment to write about this and very divergent opinions among the students.

    • Austin, glad to hear about your hospice analysis project, which will certainly be of value, but I’m a bit perplexed about the assertion that hospice is the only Medicare benefit that promises to save money. Preventive care is often claimed to do so; that is in fact false overall (ref Louise Russell and others) but some preventive benefits do indeed save a great deal of Medicare money, influenza vaccination doing so through reduced hospitalizations.

      Likewise, while one couldn’t claim that the Medicare drug benefit overall saves money to Medicare (though by enabling 12 million seniors enrolled in MA plans to avoid the cost of Medigap policies it has fattened their retirement wallets), many covered drugs do indeed save a great deal in postponing or avoiding more costly treatments.

      That said, the money saving claim certainly was trumpeted for hospice. That benefit exists today mainly because then HHS Secretary Margaret Heckler personally carried the day within the Executive Branch.

    • @Walton Francis
      those are fair examples, esp rhetorically. I agree with your skepticism about preventive care saving $. I do think hospice has had a stronger expectation of saving money than any other part of the benefit, and was really a part of the argument to add the benefit back in the early 1980s