Trustbridge News

Solutions That Make Sense: Why Hospice Benefit Reform Needs to Incorporate Concurrent Care

By Jim Parker | June 9, 2023

Increasingly, both policymakers and providers are seeing potential opportunities to reform the Medicare Hospice Benefit, including the prospect of concurrent care.

Driving these conversations is the need to lighten the nation’s heavy health care spend, which in 2021 reached $4.3 trillion, according to the U.S. Centers for Medicare & Medicaid Services (CMS).

Questions are also percolating around the long-term viability of the six-month terminal prognosis requirement.

The rising prevalence of diagnoses like dementia is leading some to posit that the hospice benefit — initially designed for cancer patients — could use an update. That point was made this week by Rep. Earl Blumenauer (D-Ore.) at a Hospice Action Week luncheon held by the National Hospice and Palliative Care Organization (NHPCO) and Hospice Action Network.

“A lot has happened since the [Medicare Hospice Benefit] was first initiated. It’s played a critical role in helping people be able to deal with the most difficult times,” Blumenauer said. “As you see the health needs change, we’re finding out in terms of the explosion of issues dealing with dementia that we’ve got work ahead of us in terms of being able to modify the benefit structure, making it more effective and meeting the needs of patients.”

We’ve got work ahead of us in terms of being able to modify the benefit structure, making it more effective and meeting the needs of patients.-Rep. Earl Blumenauer (D-Ore.)

Dementia has become a frequently-invoked example of how seniors’ changing health needs may necessitate updates to the systems designed to care for them. During the past several years, neurological conditions like Alzheimer’s, Parkison’s and other forms of dementia have become the largest group of primary terminal diagnoses among hospice patients.

Patients with dementia-related illnesses represented 18.5% of hospice enrollees in 2020, compared to 7.5% for cancer, according to NHPCO.

Hospices can likely expect an even more substantial influx of dementia patients in the coming years. The World Health Organization (WHO) projects that the number of dementia patients worldwide will rise 40% between 2021 and 2050.

Patients with these conditions also tend to have the longest lengths of stay.

In 2020, the average hospice length of stay for individuals with Alzheimer’s, Parkison’s or other dementias disease reached 143 days, NHPCO reported. This is compared to an average of 88 days for the overall hospice population and 50 days for cancer patients.

Data like these have far-reaching impacts. Not only do they signal a patient population in flux, but they also contribute to widespread concerns about regulation and an overarching desire to rein in overall Medicare spending.

“When Medicare was created in the 60s, the program had a lot more people paying into it than you had actually people receiving the program. So it worked for a long time. Now, you’ve got a lot more people who are receiving the benefit than are paying into it, and you’re starting to see an imbalance,” Rep. Joe Morelle (D-N.Y.) told Hospice News. “If you don’t have enough people paying into the payroll tax system to fund Medicare, it’s going to put a lot more pressure on the Medicare system.”

Relieving the pressure

To help relieve some of those pressures, CMS, its contractors and other agencies have been cracking down on apparent instances of fraud, waste and abuse throughout the health care continuum.

Health care fraud does occur in hospice and elsewhere, but some of the factors that regulators see as red flags — live discharges and longer lengths of stay — could also be explained by the rising number of dementia patients electing the benefit.

People with those diagnoses, for example, represent a large proportion of live discharges, according to a 2021 study in the Journal of the American Geriatrics Society.

This often leaves hospice providers between a rock and a hard place when it comes to eligibility, Tarrah Lowry, COO of the Florida-based hospice provider Trustbridge, said.

“We always are worried about a long-length-of-stay patient with dementia or Alzheimer’s diagnosis,” Lowry told Hospice News. “It’s hard to take care of those patients and then to have to go back to that family in six months, eight months or whenever to say that there’s not enough of a decline. ‘I’m so sorry, we have to leave you now.’ It’s one of the hardest things to do, knowing that there’s nothing else for them.”

[Live discharge] is one of the hardest things to do, knowing that there’s nothing else for them

-Tarrah Lowry, COO, Trustbridge

Providers and industry groups have proposed a number of potential reforms that could help to reconcile regulatory requirements with a changing set of clinical realities.

These range from extending or eliminating the terminal prognosis requirement to allowing some types of concurrent care, perhaps through a dedicated community-based palliative care benefit.

And thanks to recent research, providers have more arrows in their quivers when it comes to making those cases.

Case in point, the Center for Medicare & Medicaid Innovation’s (CMMI) Medicare Care Choices Model (MCCM) demonstration found that concurrent palliative and curative services reduced patients’ total cost of care by 14% compared to a control group — about $7,254 per individual. This was largely due to reduced hospitalizations and emergency department visits.

“Take a look at our current site. See the value of those earlier [than hospice] services. Look back to MCCM, which showed that, when we’re able to provide even a limited amount of concurrent care, we’re able to reduce emergency room visits, reduce days in the ICU, or increase the number of days at home,” Logan Hoover, VP of policy and government relations for NHPCO, told Hospice News. “Move that upstream, and we’re going to get their earlier referrals.”

Some versions of this may already be in the works.

CMMI has indicated that it would be incorporating aspects of MCCM into future models pertaining to palliative care, and, on Thursday, four U.S. senators introduced a bill that would mandate a palliative care payment model demonstration.

Blumenhaur also recognized concurrent care as a potential avenue for reform.

“Working through issues of concurrent care, it drives me crazy, the notion that we’re going to take somebody in [to hospice] and make them jump off when we know that concurrent care actually is better care,” Blumenauer said. “We have an opportunity to extend quality life and, ultimately, actually save the government money if we do it right.”

Hospice advocates can now also draw on a new study that shows that longer hospice stays generate greater Medicare savings, as high as 11%.

Hospice care — regardless of length of stay — saves Medicare approximately $3.5 billion for patients in their last year of life, a 3.1% reduction. But those with stays of six months or more yielded the highest percentage of savings, according to a joint report released in March by NHPCO, the National Association for Home Care and Hospice (NAHC) and NORC at the University of Chicago.

“For many years, everyone has wanted to give us credit for being wonderful. But they’ve always said that we cost too much money,” Lowry said. “And the NORC study is showing that even in long-length-of-stay patients we’re still saving money for Medicare, which is huge.”

Many policymakers, operators and other stakeholders have called for a collaborative approach between government and the industry to find possible solutions.

“There’s no shortage of problems in the world, but it’s important to have people who will work with you to come up with the solutions that make the most sense,” Rep. Beth Van Duyne (R-Texas), told Hospice News. “That’s the kind of policy that we’re trying to push forward, thanks to those folks for bringing us forward solutions.”