There’s life and there’s death. It’s dichotomous… sort of. Dying is a process toward the end of life, and that’s where we find end-of-life care and associated challenges.
Payers, sometimes ghoulishly, half-jokingly note that when a member with a costly condition dies, the payers’ costs end. While that’s uncomfortably true, it may not be economically advantageous. When a patient dies, purchasers’ payments to plans also end. This is a financial loss to plans when risk-adjusted payments adequately covered the member’s costs. And this is a loss when plans’ case- and disease-management programs improve outcomes and reduce costs below these payments. Only when costs exceed the payments does death end any financial losses.
When less is more
For some, end-of-life care focuses on curative treatments. Too often, this care is clinically and financially toxic. And too often, the final days are spent in a hospital on life support. For others, end-of-life care can focus on palliative, supportive, and hospice care — comfort care — typically after trying multiple lines of therapy.
The use of palliative and hospice care for those no longer seeking a cure has been shown to be cost-effective while boosting quality of life and satisfaction with care. It may surprise many to learn that palliative care often leads to longer survival. That’s right — the most aggressive and costly curative treatments toward the end of life may diminish quality of life and shorten it. One high-profile example: Former President Jimmy Carter entered hospice a year and a half ago after turning 98 years of age. Now approaching 100, Carter hopes to vote in this November’s election.
What’s best for Carter, however, is not what’s best for all. End-of-life decisions are complex. There are clinical, financial, physical, emotional, social, and spiritual considerations. These decisions should be made by patients and their caregivers in consultation with the patient’s physician. Most people are in support of healthcare providers discussing end-of-life care issues with patients. Who could argue with that?
The kiss-of-“death panels”
During the 2009 Congressional debate over the Affordable Care Act (ACA) legislation, former Alaska Governor Sarah Palin weaponized an ACA provision that would have reimbursed physicians for voluntary advance-care planning consultations with Medicare patients — describing them as “death panels.” It was a lie that went viral among conservative politicians and commentators. The ACA survived but passed in 2010 without this provision, despite widespread support for it among patients and providers. But this only slowed the march of progress. Medicare resurrected the spirit of the provision in 2015 by adopting a rule to reimburse physicians for advance-care planning consultation.
Medicare coverage of end-of-life care
Approximately 80% of people who die in the United States each year are on Medicare, and about 25% of Medicare spending on beneficiaries aged 65 or older is spent during their last year of life. It is, therefore, important that Medicare policy gets end-of-life care right.
Medicare beneficiaries are currently eligible for a comprehensive set of healthcare services for curative and/or palliative purposes until their death. These include:
- A hospice benefit (introduced in 1982) for terminally ill beneficiaries (those expected to die within 6 months if the illness runs a normal course) who waive the right to Medicare payment for services intended to treat their terminal condition and related conditions. The hospice benefit pays for nursing care, counseling, palliative medications, and up to 5 days of respite care to assist family caregivers
- Advance care planning to help individuals (a) learn about healthcare options that are available for end-of-life care; (b) determine which types of care best fit their personal wishes; and (c) share their wishes with family, friends, and their physicians
A false dichotomy
“Curative care or palliative care” is, or should be, a false dichotomy. End-of-life care decisions are, or should be, more nuanced than that. Some patients want curative care, some want palliative care, and some want palliative care and curative-type treatment (e.g., chemotherapy, radiation therapy, dialysis, transfusions) for palliative reasons, to help manage symptoms. It is time to bury the notion that curative care and palliative care are mutually exclusive.
Medicare introduced the Medicare Care Choices Model (MCCM) in 2016, a 6-year pilot program allowing beneficiaries nearing the end of life to receive hospice-like support services from hospice provider while still receiving curative treatment. A Mathematica analysis of the program showed that, relative to a comparison group, MCCM enrollees:
- Used hospice care more often and entered hospice earlier
- Spent more days at home
- Had fewer inpatient admissions and ED visits
- Yielded significant cost savings
But for several reasons, including low participation rates among providers and beneficiaries, the authors conceded that these results are likely not generalizable and that new approaches are needed. On a more positive note, the MCCM results informed end-of-life components of four new models being piloted by the CMS Innovation Center (the Guiding an Improved Dementia Experience model; the Value Based Insurance Design (VBID) model; the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model; and the Kidney Care Choices model) that allow hospice and palliative care providers to offer supportive and palliative care services concurrently with conventional treatments.
Commercial payers get the value of end-of-life palliative and hospice care. They cover both. And some commercial payers wisely cover concurrent care, what is sometimes referred to as “open-access hospice,” in which patients receive palliative or hospice-like services along with curative treatments. This approach can increase participation in hospice care and reduce costly end-of-life hospitalization. Aetna’s Compassionate Care Program, for instance, provides case management, education, and support for members with critical illness and allows for hospice-like support services and curative care.
Ending a false dichotomy
We need legislation that authorizes Medicare reimbursement for concurrent care, allowing patients to receive simultaneous curative-type treatments and hospice-like care. Doing so could breathe life into reimbursement for concurrent care by commercial plans. To ensure successful implementation, we need to approach the legislative process strategically, learning from the “death panels” case study and help to ensure that a lie is not a kiss of death for legislation people want.
As we’ve seen, end-of-life care decisions are fraught with emotions and end-of-life care policies are more easily weaponized. Effective communication is needed to protect a new open-access hospice policy from lies and counter attacks by emphasizing that concurrent care is patient-centered and offers choices that may best suit a patient’s needs, is the opposite of rationing healthcare, its coverage corrects a current overreach by government, and it is cost-effective. If crafted thoughtfully and communicated effectively, legislation for concurrent care options could appeal to people across the political spectrum and potentially garner bipartisan support.
Reimbursement for concurrent care is necessary but likely not sufficient and, if won, there is no time to rest. Hospice providers will likely need help coordinating care with other providers and helping patients physically get to those treatments. And we’ll need effective communications to ensure that both patients and providers are aware of and understand the benefits of concurrent care. But let’s start with reimbursement and then tackle the rest.
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