Hospice Physician Timothy Ihrig: MA Carve-in May Hurt Quality

Hospice and palliative care physician Timothy Ihrig, M.D., is chief medical officer of Crossroads Hospice and has served in that role since 2018. He speaks nationally on policy, clinical and economic issues that impact hospice and palliative care providers and their patients. 

Crossroads provides hospice and palliative care to approximately 1 million patients annually in Georgia, Missouri, Oklahoma, Pennsylvania, Ohio, Tennessee, and Kansas. The organization’s average daily census is 2,400, 74% of which are hospice patients.

The Center to Advance Palliative Care has endorsed Ihrig as a clinician-educator, and he consults with palliative care providers nationwide and internationally. In his TED Talk, “What We Can Do to Die Well,” Ihrig advocates for physicians to focus on patients’ quality of life, in accordance with the patient’s goals and wishes, rather than fixing their attention on clinical interventions.

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Hospice News spoke with Ihrig at the National Hospice & Palliative Care Organization Interdisciplinary Conference in Orlando, Fla.

What are some of the societal, technological and policy factors that could be shaping the future of hospice and palliative care going forward?

I think the greatest challenge to hospice is the evolution of hospital systems and their desire to mitigate their downside, downstream financial risk.

With the advent of [Accountable Care Organizations (ACOs)] 10-plus years ago, and the growth and expansion of risk-based contracting in the hospital space and the hospital system space, we see that [the U.S. Centers for Medicare & Medicaid Services (CMS)], and other payers are actually putting teeth into reimbursement and penalties from a financial perspective if systems aren’t delivering positive outcomes.

Positive outcomes are not truly defined, unfortunately, as what’s sacred to you, and what aligns with your goals of care, having led with true informed consent, because that doesn’t happen — positive outcomes are really are the systems decreasing the overall spend per capita expenditure for this segment of the population. If they’re not, then they’re held accountable from a decreased reimbursement or financial penalties.

Hospice is the first to be on the chopping block, usually, historically.  We see it again when it’s time to ask, “Where are we going to squeeze money from turnip?” Let’s go to hospice, because the word is very consternating to many of the political pundits and the society at large. So how do we squeeze money out of that sector? We continue to see that over the last few years hospice is being held to a standard different than the rest of the system. 

Back in 2013, and 2014, in an attempt to stomp out quote-unquote fraud, you saw this with the [U.S. Department of Health and Human Services Office of the Inspector General and the Department of Justice] jumping in. We’ve seen so many hospices go belly up, because there is a methodology that is not valid for evaluating the care that’s being delivered, and people are held accountable to outrageous, non-relevant fines. Small hospices with an average daily census of 70 or 80, are being fined as much as $40 million.

When we look upstream of that, there’s no system that’s being held accountable for quote-unquote fraud. If you have an end-stage diseases that are actively dying and they still offer support to potentiate majorly invasive, expensive procedures that absolutely will not change the outcome. There’s a double standard from a from an oversight perspective.

I think that’s a big threat to hospice.

Back to the ACO health care systems, what we’re seeing is they are wanting to own attributable lives from birth to death. And so if they have the means, and many think that they do, of providing end-of-life care outside of the hospice Medicare insurance benefit, they’re going to try to promote that because they don’t want to be held accountable to the regulatory issues that hospice has in place. 

That’s concerning to me as a provider. It’s concerning to me from an organizational perspective as well.

What are your thoughts on the Medicare Advantage hospice carve-in is planned for 2021?

I have seen no details, and that’s frightening. Who’s sitting at that table? I can speculate that it’s not a lot of hospice providers or physicians. Rather, if you follow the money stream, it’s probably a lot of your big [Medicare Advantage] plans.

And so the threat is, what is the quality of care going to be? That’s fundamentally my greatest concern. How do we hold people accountable for the highest level of care, for understanding that the last few chapters of life and end-of-life care is very different than then your linear algorithmic formula that systems potentiate of doing things to people?

CMS says it’s going to provide access to a lot more individuals. Access is one thing, how do we ensure quality? That that is yet to be determined.

 How do we ensure timely referrals? How do we ensure that — if it’s consistent with somebody’s goals of care — that they can have a transition to a hospice level of care that day without a prior authorization? 

The system of medicine is such that, for the most part, people are transitioning to hospice at the very bottom of the ninth inning. So with the Medicare Advantage carve-in, who is going to regulate timeliness of referrals, appropriateness of care, oversight of care, and what is the payment methodology? It’s a perspective of let’s make money, and that precedes the notion of patient first. So that’s a grave concern.

 And I challenge some of the larger academies who have taken the position that it is going to improve and increase access to hospice. Again, that’s not enough. There has to be some accountability. Access to poor care is still poor care.

Similar question, what do you see happening in the palliative care space?

It’s being influenced more and more by organizations feeling the financial pinch of accountability through CMS and payers for the advanced illness population and still just 1% to 3% of their attributable lives. But there’s about 1% to 3% of the health care systems’ attributable lives that are costing them money.

What we’ve seen the spring of this year is two distinct reimbursement models [the Primary Care First and the Seriously Ill Population models], and obviously that’s tethered to the policy at some level to promote care outside of the hospital, non-acute care, so community-based home care, and one is to incentivize, financially, primary care providers. [Primary Care First-general option] is really similar to the medical home model, and then the [Seriously Ill Population model] is to potentiate palliative care.

My concern with that is: You have a system that’s broken, period, for this population, for the advanced illness population. It does not work. And regardless of where you deliver that care, it’s still the same process and method of delivering care that fails this population. 

Even if we take it to the home, it’s still the wrong care. We have a system that potentiates doing things to people based on disease and ability and not based on physiologic realities or true patient choice. Patients aren’t told the truth. If you have widely metastatic disease and the mean life expectancy is “X,” people aren’t privy to that. So the system is stealing choice from people.

I see that to mitigate costs there are these incentives in the non-acute space. Is it going to be a game changer? Empathically, I would say no, because you’re just giving the same care at a different location. We are not changing the narrative. We’re not moving it upstream to offer realities and choice beyond the bottom of the ninth inning. So it’s going to be very, very interesting over the next 18 to 24 months. 

How might hospice and palliative care change with the advent of value-based payment models such as the Medicare Advantage carve-in and the Primary Cares Initiative?

I think hospices generally are very passive, and some of the larger academies have suggested that they remain so and absorb whatever changes come their way. I think is antithetical to what we need to do. We need to take a stand and demand to sit at the table. We need to hold ourselves accountable for being relevant. 

Particularly now, when there’s so much focus on end-of-life care and those individuals that cost a lot of money; that’s the perception from the systems. But, emphatically, the elderly and the ill — and that’s generally who we’re talking about — don’t cost money because they’re elderly and ill. They cost money because of what systems do to them.

So you have the aggregate per capita reduction in expenditures for all ACOs; about a year-and-a-half ago was 1.25%. That’s laughable. And I challenge all those institutions: How much money did you spend to create processes within a system that has repeatedly failed? And how many tens of thousands of hours were spent to achieve a 1.25% reduction in expenditure across this population?

Again, the narrative from most of the academies and the systems is that we’re trying to say care for people at the end of life. If they really wanted to care for them, we would change the structure and the process and operationalizing how they actually understand that which is done to them, either to potentially increase life expectancy or increase life quality, and it really is the thing that that cost them financially.

So it’s not about health care reform. We need to reform how we care. The institution is flawed with respect to care in general, but specifically in the population we deal with, served by palliative and hospice. 

The electric light was not invented by improving candles, but everybody’s still working in wax. That’s the biggest challenge I see. We are never going to be successful in caring for people — and thus mitigating that financial risk — if we continue to act in the same manner we have the last 30 years.

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