TRICARE, the U.S. military’s health insurance program for uniformed service members and their families, will now pay for medical treatment concurrently with hospice care for pediatric patients with terminal illness.
The rule change, made in accordance with the National Defense Authorization Act of 2018, applies to military dependents who are younger than 21. Before this action, TRICARE patients, including children, were required to choose either curative treatment or hospice, similar to the enrollment requirements for the Medicare Hospice Benefit.
Concurrent care is important for pediatric patients, which, while a small population, are more likely to respond to curative care while in hospice than elderly adults whose determination to enter hospice is often prescribed for end of life management,” Kevin Dwyer, chief of media relations for the Defense Health Agency, told Hospice News. “Pediatric cases are unique as it is difficult to predict the length of survival for many childhood diseases.”
The Affordable Care Act in 2010 contained provisions allowing pediatric hospice patients who are covered by Medicaid to receive concurrent care. TRICARE, whose stipulations tend to dovetail closely with those of Medicare, did not change their policies.
The advocacy organization TRICARE for Kids Coalition pushed hard for approval of the new policy.
“Allowing for concurrent care reflects the better understanding that we have gained through the years of children with complex illness and how their conditions are best treated and the types of care models that are being used,” Kara Oakley, chairperson of TRICARE for Kids Coalition. “We have to make sure that military-connected children and families can get the care that they need.”
TRICARE will cover hospice in military facilities as well as hospice care provided in the home, the preferred setting for most hospice patients. TRICARE presently will not cover concurrent care for adult patients.
“That certainly was the intent to ensure that patients can have true hospice care, where clinicians come into the home and really care for the whole family,” Oakley said. “To be able to have care that involves the whole family is always important, especially in an end-of-life situation.
Research has indicated that continuing other treatments during hospice has medical benefits for adult patients and can help control or reduce health care costs.
A recent study of more than 13,000 veterans in Veterans Affairs Medical Centers (VAMCs) found that patients receiving hospice care concurrent with chemotherapy or radiation therapy were less likely to use more aggressive treatments or be admitted to intensive care compared to similar patients who were not enrolled in hospice, significantly reducing medical costs. Unlike TRICARE or Medicare, the Veteran’s Health Administration (VHA) allows adult patients to receive treatment while in hospice.
Medicare covers most hospice care delivered in the United States Though beneficiaries enrolled in the hospice benefit currently must forgo curative treatment, the U.S. Centers for Medicare & Medicaid Services (CMS) is exploring alternatives to that policy through the test of its Medicare Care Choices Model, which the agency launched in 2016 and plans to conclude in 2020.
The model allows participating hospices to provide services that are currently available under the Medicare hospice benefit, but cannot be separately billed under Medicare Parts A, B, and D, while enrollees are also pursuing curative treatments. CMS pays participants a fee ranging from $200 to $400 per patient, per month while they are delivering services under the model, including care coordination, case management, symptom management, and other support for beneficiaries and families.
Following the conclusion of the program CMS will begin an evaluation phase expected to last two to three years. In addition to assessing the impact on costs, CMS is studying the impact of the model on patient satisfaction and the quality of care.
Currently 96 hospices nationwide are participating. Though participants hospices reported that they were losing revenue via the program in the early phases, CMS theorizes that losses could be offset by increased utilization.
“Having to forgo Medicare payment for treatment aimed at curing the terminal condition may impede the choice of electing hospice care,” the agency indicated in a 2017 announcement of hospices the agency selected as participants. “[The model] tests whether eligible Medicare and dually eligible beneficiaries would choose to receive hospice support services, if they could also continue to receive treatment for their terminal condition.”