CMS Report: Concurrent Hospice, Curative Care a Winning Proposition

The Medicare Advantage hospice carve-in has been the focus of much attention among providers, and many are watching closely for the demonstration’s outcomes.

But for the past four years, a lesser-known payment model demo, the Medicare Care Choices Model (MCCM), has been hitting every target — reducing costs, improving quality and family satisfaction, and keeping patients in their homes.

The U.S. Centers for Medicare & Medicaid Services (CMS) launched the MCCM in 2016 to explore the idea of allowing hospice patients to receive concurrent curative care. Initially slated to complete in 2020, CMS extended the program until December 2021.

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If such a model were to be implemented permanently, it would allow patients who are afraid or not ready for hospice care to receive the benefits without losing access to other services, according to Edo Banach, president and CEO of the National Hospice and Palliative Care Organization (NHPCO).

“If you get access to curative and palliative care, quality goes up and costs go down. There are folks who are scared to choose hospice who choose something that gives them access to curative care, which for some chronic conditions and serious illnesses there is none,” Banach said at the Hospice News Palliative Care Conference in Chicago. “But once they made that leap, they sought more palliative care, less curative care, within hospice.”

Results from MCCM appear to bear out that perspective. CMS recently published its annual report for the program, which indicated that the model was achieving virtually every one of its goals.

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The recent report focuses on 4,574 Medicare beneficiaries who enrolled in the program between January 2016 and September 2020 and who died by March of 2021. The enrollees were Medicare fee-for-service beneficiaries with a six-month terminal prognosis, with a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS.

These patients had also received a referral to one of the program’s 141 participating hospices, met eligibility criteria for the demonstration and made the choice to enroll in MCCM.

“Our impact estimates largely align with the expectations of the model — that is, they match the pattern of outcomes MCCM intended to produce,” CMS said in the report. “Although their paths varied, MCCM beneficiaries ultimately appeared to have received better-quality end-of-life care according to established quality measures, such as spending more days at home at the end of life.”

The total net cost of care for MCCM patients was 14% less than those for a control group, generating about $7,254 in savings per individual, the report indicated. This was largely due to reduced hospitalizations and emergency department visits compared to a control group.

Those who were hospitalized spent fewer days in intensive care units and had shorter stays, according to CMS. They also were more likely to eventually accept the Medicare Hospice Benefit. About 83% of enrollees transitioned out of MCCM and into traditional hospice, which accounted for nearly 70% of the savings, the agency reported.

CMS did cite a few caveats in its impact analysis, such as relatively low rates of enrollment in the program as some differences in patient/provider characteristics compared to non-participants.

“Sensitivity analyses suggest these unobserved differences would have to be very large to fully negate the findings, but perhaps true impacts were not quite as large as we estimated,” the report said. “Thus, careful consideration is merited for hose extrapolating these findings to other settings.”

Despite these acknowledgments, signs point towards positive results. A previous CMS report released in November 2020 found that at that point the demonstration had reduced the agency’s costs by $26 million. The agency plans to publish a final report in 2023.

The question of concurrent care dates back to the establishment of the Medicare Hospice Benefit, according to Banach.

He told Hospice News that when CMS and other stakeholders were designing the benefit, the White House Office of Management and Budget (OMB) set the condition that if the agency was going to cover hospice, then it could not also pay for curative care for those patients.

“The original sin of the hospice benefit was when [OMB] said we’re not going to let this through, unless you make people give up [curative care],” Banach said at the conference.”They were wrong, because when you actually give people access to more, they choose less.”

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