CMS SAYS MEDICARE CARE CHOICES MODEL IS REACHING ITS GOALS
- In 2016, CMS initiated the Medicare Care Choices Model (MCCM) program. The program was conceived to help understand what happens if eligible patients are allowed to receive “support services without forgoing payment for treatment of their terminal conditions.” The program seeks to learn if this “improved their [recipients] quality of life and care, increased beneficiaries’ satisfaction, and reduced Medicare expenditures.” While the model was to end in 2020, CMS lengthened the program through December 2021.
- CMS’s latest report evaluates MCCM outcomes through March 2021, and the results are encouraging. At the beginning of MCCM, CMS selected 141 hospices to participate in the model, and 89 of these hospices (63%) served at least one beneficiary by the end of September 2020. Forty-nine hospices (35%) elected to be a part of the extended program for an additional year. Participating hospices, throughout the project “tended to be larger than other hospices nationwide, and more often were a part of nonprofit organization.”
- Medicare beneficiaries who chose MCCM met hospice criteria and had diagnosis of cancer, congestive heart failure, COPD, or HIV/AIDS. Those who participated “received supportive services through MCCM and coverage under the Medicare fee-for-service benefit for both their terminal illness and other health care needs.” By the end of September 2020, the model had served 6,427 participants. The participants represent a small percentage of individuals who met the criteria for admission set by CMS. These enrollees tended to be more ill and use more services; and a “disproportionately higher percentage had cancer than non-enrollees.” Five of the hospices enrolled 45% of all of the MCCM participants. While enrollment for the beneficiaries averaged 185 days, the survival rate of participants range from one day to two years.
- The impact analysis includes a study of 4,575 of the participants who received services from January 2016 through September 2020, and who died by March 2021. Significant findings include:
- “Reduced Medicare Expenditures.” Overall costs for these patients was 17% “lower than expenditures for comparison group beneficiaries.” Payment to participating hospices resulted in a 14% net decrease in payment. The greatest savings was for those enrolled for 21 to 365 days, and “the largest percentage impacts were concentrated among enrollees who lived fewer than six months after enrolling in MCCM.”
- “Reduced use of resource-intensive services.” MCCM enrollees were less like to be hospitalized. “They had 26 percent fewer inpatient hospital admissions and 14 percent fewer outpatient emergency department visits and observation stays than beneficiaries in the comparison group.” Enrollees spent 38% less user days in intensive inpatient care and 30% fewer days in the hospital, leading to overall reductions in Medicare costs.
- “Increased use of the Medicare hospice benefit.” Eighty three percent of the MCCM enrollees “transitioned out of MCCM and subsequently enrolled in Medicare hospice benefit.” The analysis revealed that “about 70 percent of the Medicare savings….were due to MCCM enrollees enrolling in hospice care earlier and more often.”
- “Improved quality end-of-life care.” Family members of enrollees with MCCM report better end-of-life care for patients, from enrollment until death. Aggressive life-extending care was less frequent during the last 30 days of life (46% vs 62%). They also experienced a four percent increase in days at home.
- In the executive summary of the report, there is chart that outlines “the evaluation’s primary quantitative beneficiary outcome measures.” The data analysis showed that, across subgroups of the MCCM participants, there were some differences in the outcomes. These include:
- “Qualifying condition.” Findings indicate that all the subgroups—cancer, congestive heart failure, and COP—experienced “remarkably similar” effects.
- “COVID 19.” The outcomes of MCCM participants appear to be sustained during the pandemic. Reduced costs for Medicare was even larger for MCCM patients who enrolled during the pandemic than for those who enrolled before the pandemic.
- “Health equity.” “Racial minority and dually eligible MCCM enrollees had less favorable outcomes than non-Hispanic White MCCM enrollees and Medicare-only MCCM enrollees, respectively, on several quality-of-care outcome measures.”
- Overall, the data show that the impact and expectations for MCCM “match the patterns of outcomes MCCM intended to produce.” MCCM enrollees “appeared to have higher quality end-of-life care, spent more days at home, and had lower average Medicare expenditures and acute care services than did those in the control group. Careful examination is important, however, as the report notes that some of the “unobserved differences” could impact the findings. The link below leads to the full report. (CMS, April 2022, https://innovation.cms.gov/data-and-reports/2022/mccm-fourth-annrpt)
Because of recent changes in the state budget, New York home health workers will receive a $2 an hour wage increase on October 1, and by an additional dollar per hour one year after that. But this is a problem for hospices. Since hospices provide home health aide services, they are required to pay this increase in wages. Jeanne Chirico, president and CEO of the Hospice and Palliative Care Association of New York State, says there is a lack of “clarification on how or if the state will reimburse providers of hospice care who employ home care workers.” Several NY bills would also impact hospice patients and providers. A.880S.8205 would create an “advance planning campaign to promote hospice and palliative care services. A.8881/S.8206 would create an office “of hospice and palliative care access and quality within the Department of Health. Bill 1.8006/S.7626 would authorize assisted living resident to access hospice if they wish. “‘It’s time that the state and the people of this state recognize that this benefit, if we want it to continue to be provided in New York, needs some assistance,’” says Chirico. (Spectrum New 1, 5/2, https://spectrumlocalnews.com/nys/capital-region/politics/2022/05/02/ny-hospice-advocates-push-three-bills-in-light-of-budget-loss)
Health Affairs reports on findings of research on end-of-life care for residents of assisted living communities. Researchers explored “death at home and home hospice care,” of “100,783 fee-for-service Medicare beneficiaries residing in 16,560 assisted living communities who died in 2018-19.” They found that about 60% died at home, and 84% died with home hospice. They found that dually-eligible patients were more likely to die at home, regardless of race or ethnicity. “Residents were less likely to die at home or with home hospice in states with lower regulatory stringency.” The researchers hope the finding improve “equitable access” to the preferred end-of-life care.(HealthAffairs, May 2022, https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2021.01677?journalCode=hlthaff\)
A recent study, reported in JAMA Health Forum, asked, “Did hospice use for persons with Alzheimer disease and related dementias (ADRD) change between 2008 and 2019 in conjunction with Medicare policy changes that aimed to reduce long hospice stays? Researchers discovered that these changes “were associated with lasting reductions in the share of patients receiving hospice care admitted with an ADRD code compared with expectations based on pre-implementation trends.” The researchers call for examination of the “mechanisms” that hospices used for these changes, and the results of the changes in terms of quality of care. The article includes details about the project, methodology for the study implementation, and a discussion of findings. (JAMA Health Forum, 5/6, https://jamanetwork.com/journals/jama-health-forum/fullarticle/2791963)
PALLIATIVE CARE NOTES
New data reveal “that the symptoms suffered by people with advanced Alzheimer’s disease and related dementias who live in the community occur at a strikingly similar rate to those of dementia patients in a nursing home.” The data comes from a five-year baseline survey “funded by the National Institute on Aging named IN-PEACE (Indiana Palliative Excellence in Alzheimer’s Care Efforts) and analyzed responses from caregivers regarding symptoms.” Regardless of location, the patients’ most common symptoms were pain, agitation, anxiety and resistance to care. Over 40% experienced these symptoms at least weekly. The symptoms were obvious and frequent and lessened quality of life. Researchers hope to find that palliative care relieves these difficult symptoms. (Science Daily, 4/27, https://www.sciencedaily.com/releases/2022/04/220427100600.htm)
An article posted at ehospice features a conversation with physician Ira Byock discussing the “Intentional Branding of Palliative Care.” Byock calls on palliative care advocates to “embrace an authentic, life-affirming brand of palliative care.” Byock and others will be sharing at the October International Conference of Palliative care on “The Public Face of Palliative Care: The Brand We Want to be Known By.” In the online article at the link below, Byock reviews the path that palliative care has taken thus far and perceptions of palliative care. He calls for authenticity in care—beginning with our name and owning it. He recognizes the challenges and calls for reaching consensus about what “palliative care mean.” (ehopsice, 5/1, https://ehospice.com/editorial_posts/conversation-with-ira-byock-intentional-branding-of-palliative-care/)
An article in Next Avenue offers a conversation with Anita Hannig, author of “The Day I Die: The Untold Story of Assisted Dying in America.” The article shares that 20% of Americans live in places that allow assisted dying. Oregon was the first state to allow this via its Death With Dignity Act that became law 25 years ago. All nine states and D.C. that have legalized the practice have their own versions of the law. But all of them require “that the patients must be of sound mind, have less than six months to live and they must be able to self-administer the lethal mediation, prescribed by a physician, to end their lives.” In a recent survey, 67% of responders agree that they want the option if they should face incurable illness. And the issue is expected to become even a “bigger issue in the years ahead” as the baby boomers age. Hannig, in writing her book, spent five years “on the frontlines of assisted dying in the Pacific Northwest.” The article shares a transcript of the conversation with Hannig. (Next Avenue, 5/3, https://www.nextavenue.org/less-alienated-from-death-and-dying/)
Weill Cornell Medicine’s Center for Research on End-of-Life Care” has issued a call to “palliative and critical care clinicians, as well as other clinicians/students who care for patients and families with serious illness.” The call is to join a study to help identify issues related to “addressing disparities in end-of-life care for patients with intellectual/developmental disabilities.” The study intends to develop training for “palliative and critical care clinicians and healthcare students.” Participants in the study will be ask to “watch or read a brief education resource,” and answer pre- and post- questions. Participants will be helping to improve training and to learn about “caring for a vulnerable patient population.” The first link below leads to the Center, and the second link contains an application to join the study. (Weill Cornell Medicine Center for Research on End-of-Life Care, https://endoflife.weill.cornell.edu/about-us; Weill Cornell Medicine, https://weillcornell.az1.qualtrics.com/jfe/form/SV_6DSmp7lGiBxNgGx)
“Health care professionals work to address inequities in palliative care” appears in State of Reform. The article reports on a panel presentation that was focused on ways to address inequities in end-of-life care. The panel was hosted by The Washington Serious Illness Care Coalition, and the panelists examined factors impacting racial disparities in end-of-life care. They spoke to “preferences in languages, religious beliefs, preferences in treatment, and quality of care.” The Journal of Palliative Medicine, says the article, suggests that there is growing evidence “that racial and ethnic disparities exist in access to palliative care and in clinical outcomes such as symptom management and communication.” The panelist explores several cultures and ethnic groups and share experiences about how they are addressing these issues. (State of Reform, 4/29, https://stateofreform.com/featured/2022/04/panel-aims-to-resolve-inequities-in-palliative-care/)
The transcript of CMS’s April 26 National Stakeholders Call is now available online at the link below. At the top of the report is a link and password to listen to the webinar. (CMS, 4/26,https://www.cms.gov/files/document/transcriptoaquarterlynationalstakeholdercall04262022.pdf)
Medpage Today reports that “Medicare Advantage plans often denied medically necessary care to beneficiaries and payments to doctors that met Medicare coverage rules.” The findings of new report of the Office of Inspector General reveals “that 13% of prior authorizations requests that were denied met Medicare coverage rules, as did 18% of physician payment requests that were turned down.” The denials often involved advanced imaging care and stays in post-acute care facilities.” The Medicare Advantage Organizations plans use clinical criteria that Medicare coverage rules do not contain and there are errors as well. In spite of approving a big majority of requests for services, there are “millions of denials each year…” As Medicare Advantage plans cover increasing numbers of beneficiaries, concern about these denials is growing. Of all Medicare beneficiaries, 42% are enrolled in a Medicare Advantage plan. By 2030, that number is projected to increase to 51%. The first link below is to the Medpage Today article and the second link is to the OIG report. (Medpage Today, 4/29, https://www.medpagetoday.com/special-reports/exclusives/98458; OIG, April 2022, https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf)
While Congress will allow telehealth to continue for some period of time, a permanent change has yet to be confirmed. HHS Secretary Xavier Beccara and OIG “indicate that HHS is committed to expanding telehealth beyond the end of the PHE,” and “OIG recognizes the long-erm benefits of access to these services.” Congress has asked MedPAC to review expansion of telehealth and make recommendations by June 15, 2023. OIG has also created a resource page “dedicated to telehealth and the OIG’s evaluation of such services.” The first link below is to an article in Healthcare Law Insights, and the second link is to the OIG resource page. (Healthcare Law Insights, 5/4, https://www.healthcarelawinsights.com/2022/05/telehealth-flexibilities-extended-to-late-2022-and-likely-beyond/; OIG, 4/4, https://oig.hhs.gov/reports-and-publications/featured-topics/telehealth/)
* Gary Fowler tried to get care from a number of hospitals in Detroit when he was sick with COVID. When he couldn’t find help, he “went home and wrote that he could not breathe before he died.” Oprah Winfrey heard the story and was deeply moved. Her documentary “The Color of Care,” for which she is executive and producer, “takes a deep dive into the structural racism embedded within the U.S. healthcare system. Winfrey, in collaboration with the Smithsonian Channel and Winfrey’s Harpo Productions. The director of the documentary is award-winning filmmaker Yance Ford. The film includes family members and friends of people of color and the “agonizing measures they took to obtain medical care before they passed.” The documentary premiered on 5/1 on the Smithsonian Channel and is online at the second link below. (Black Enterprise, 5/1, https://www.blackenterprise.com/oprah-winfreys-documentary-the-color-of-care-explores-the-racial-inequalities-in-the-healthcare-system/; YouTube, https://www.youtube.com/watch?v=McSrWz-1hY&ab_channel=SmithsonianChannel)
Palmetto GBA Hospice Coalition: Request for Questions
Please Circulate! The Hospice Coalition will be meeting via telecommunications with Palmetto representatives on June 9, 2022. Please route this to the individuals in your hospice agencies who deal with Palmetto routinely to see if they have any questions they would like us to raise during our meeting. Please submit questions by Friday, May13th, 2022.
You may submit questions any time they occur to you; they will be added to the list for the next quarterly meeting.
Please transmit questions via the following email: [email protected]