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by Phil Rodgers (@PhilRodgersMD)

Submit comments this weekend! Deadline: Monday, Sep 10, 11:59 PM ET

Regular Pallimed readers will remember Amy Davis’ excellent post regarding CMS’ recent proposed rule updating the Medicare Physician Fee Schedule and Quality Payment Program for 2019. (See this CMS Fact Sheet to learn more). In this rule, the agency proposes historically bold changes to outpatient evaluation and management (E/M) documentation requirements and payments, among many other substantial changes in the fee-for-service Medicare program. CMS says these proposed changes are designed to "increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare,” and they align with CMS’ Patients Over Paperwork initiative.

One of the provisions most concerning to the hospice and palliative care community is the proposal to create a single ‘blended’ payment for level 2 through 5 outpatient E/M visits (both new and established) that is lower than the current payment for level 4 visits. (See a CMS slide deck for more detail). Since many outpatient palliative care providers bill almost exclusively level 4 and 5 visits, this proposal is particularly damaging to our field. In fact, an American Medical Association (AMA) impact analysis showed that hospice and palliative care providers will be the hardest hit of all specialties, with an expected 20% reduction in outpatient E/M revenue. CMS also proposes new complexity and prolonged services payments, but they will not be sufficient to offset the cut in E/M payments.

On the positive side, the rule also includes proposals to reduce physician burden, like significantly decreasing documentation requirements (or 'note bloat'), and providing options to bill based primarily on ‘medical decision making’ or even face-to-face time. CMS also proposes new payments for technology-based services (both patient interactions and interprofessional consultation), new payments for E/M services provided on the same day by different providers in the same specialty or practice, and eliminating the requirement to justify a home visit instead of an office visit.

The reaction from the medical community to this proposed rule has been swift and significant. The AMA gathered 170 state and specialty medical societies and other health professional organizations to sign on to a letter that encourages CMS to move ahead with the positive changes in the proposed rule, but not to finalize the ‘code collapse’ proposals as written. Instead, the signatories request that CMS work with the medical community to develop payment reforms that ‘get it right’ for patients and providers, for implementation as soon as 2020.

The American Academy of Hospice and Palliative Medicine (AAHPM) has been actively engaged since the release of the proposed rule in mid-July. In addition to signing on to the AMA letter, AAHPM has worked with the National Coalition for Hospice and Palliative Care, the Patient Quality of Life Coalition, and a multi-specialty coalition led by the American Geriatrics Society, as well as participated in meetings with CMS leadership and a high-profile E/M workgroup convened by the AMA Current Procedural Terminology (CPT) Editorial Panel and RVS Update Committee (RUC). AAHPM has stressed throughout that many outpatient palliative care providers will be severely affected by the E/M payment reductions to the point of being forced to close, and that the proposed changes will likely reduce access to care for many Medicare beneficiaries with serious illness. AAHPM has also has pledged to continue very active engagement to help develop more patient-centered payment proposals.

Now it’s your turn! Public comments are being accepted through midnight (Eastern time) Monday September 10, and I strongly urge you to weigh in. It’s easier than you may think: AAHPM has provided a short and readable guide that provides suggested Talking Points and details how to submit comments online. Do check it out. You can also review these tips for effective comments from Regulations.Gov.

In addition to those resources, I’d offer the following thoughts on comment writing:

1. CMS really does read every comment received on proposed rules, and sometimes cites specific comments as leading to changes in the final regulations — so your input counts!

2. Write in your own voice, and speak to the impact the proposals will have on your practice and your patients. If you happen to have specific knowledge about regulations (say, from a leadership or administrative role) don’t be afraid to share it; however, you don’t need to be an ‘expert’ (or try to write like one) to weigh-in effectively.

3. Don’t feel like you have to comment on every issue in the proposed rule (it’s massive). Focus on those that you feel most strongly about. Sometimes a shorter, well-reasoned and well-supported comment packs a bigger punch.

4. Remember the ‘feedback sandwich’: start with something positive, then provide specific criticisms (as constructively as possible), then finish up with a positive comment. You can be a little more ‘on the nose’ in a comment letter than you would when evaluating a learner or colleague, but double down on specificity in your concerns, not vitriol or outrage. (Hint: the AAHPM Talking Points are structured in ‘sandwich’ format, and meant to strike a concerned but constructive tone.)

Bottom line: Submit comments soon! You can comment online here (https://www.regulations.gov/comment?D=CMS-2018-0076-0621) and either add text directly to a comment box, or prepare a letter and upload the file.)

Deadline is Monday, September 10, at 11:59 PM ET!

Phil Rodgers practices and teaches Palliative Medicine and Family Medicine at the University of Michigan, and directs UM Adult Palliative Medicine clinical programs. He also represents the American Academy of Hospice and Palliative Medicine (AAHPM) in multiple national advocacy efforts related to payment and policy, and is leading the Academy team developing strategy, comments and collaboration in response the 2019 MPFS proposed rule.

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by Chad Kollas

On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) published its Advance Notice of Methodological Changes for Calendar Year 2019. Included in these proposed rules were several directives intended to reduce "Opioid Overutilization” (see p. 202), including formal adoption of the “90 morphine milligram equivalent (MME) threshold cited in the CDC Guideline, which was developed by experts as the level that prescribers should generally avoid reaching with their patients (p. 203).” CMS proposed “adding additional flags for high-risk beneficiaries who use ‘potentiator’ drugs (such as gabapentin and pregabalin) in combination with prescription opioids (see p. 204).” CMS also proposes a 7-day limit for initial fills of prescription opioids for the treatment of acute pain. The proposed CMS rules are unclear about exceptions for patients enrolled in hospice or with cancer pain, but there seems to be a mechanism in place for prescribers to apply for an exception for each individual patient (p. 209-210).

On learning of these proposed CMS rules via social media, many members of the hospice and palliative medicine (HPM) community expressed several profound concerns: Foremost, how would these changes impact our patients and their care? How will the rules affect our daily practice? And, for the HPM policy wonks, how did the 90 MME threshold make its way into proposed federal policy without evidence from the medical literature.

As one of the aforementioned HPM policy wonks, I’d like to address the last question first. The 90 MME threshold was born in 2012, as part of a non-solicited petition to the Food & Drug Administration (FDA) from a group of physicians who identified themselves as subject experts and referred to themselves as Physicians for Responsible Opioid Prescribing (PROP). Ultimately, after reviewing open comments from stakeholders, the FDA declined adoption of PROP’s 90 MME proposal.

Undeterred, PROP successfully sought to place the 90 MME provision in the CDC Guideline for Prescribing Opioids for Chronic Pain, leading to criticism of the CDC for a lack of transparency by the pain management community. Ultimately, the CDC did recognize that certain patient populations, including patients receiving hospice and/or palliative care, might legitimately require opioid doses exceeding the 90 MME limit. The current CMS proposed rules, however, do not offer an exemption to this limit for these patients; they would instead further codify an opioid dose limit that was largely created in an arbitrary fashion based on a self-selected group of physician “experts” with no accountability to the HPM community.

This observation likely concerns those of us who ask how – as HPM practitioners – the proposed CMS rules will affect our practice. Of much greater importance is how these proposed rules would affect our patients. Opioid stigma in the setting of “The Opioid Crisis” is already a major barrier to patients receiving hospice and/or palliative care that adversely impacts their access to medications needed to maintain their quality of life. For example, in a recent study of 250 patients receiving outpatient palliative care at a cancer center, 54% reported feeling stigmatized for their use of opioid analgesics and 73% reported difficulty filling opioid prescriptions (Kollas CD, Boyer-Kollas B. Assessing Opioid Stigma in Oncology Outpatients Receiving Palliative Care for Cancer-related Pain. Accepted to 2018 AAHPM Annual Assembly). The proposed CMS rules, in their current form, would add to patients’ perception of opioid stigma and, at best, will result in delays in receiving medications to manage their chronic pain. At worst, some would not receive the amount of medication needed to relieve their pain, severely impacting their quality of life or driving them to desperate measures, like seeking illegal drugs. Ironically, CMS new rules could unintentionally accelerate the emerging trend in opioid overdose deaths: deaths from illicit drugs, like heroin or illegal fentanyl (see CDC data here).

While this sounds catastrophically bad, there is a small silver lining within CMS’s announcement; there will be an open period for comments from stakeholders. CMS will review all comments submitted via its website, whether submitted by an individual patient or physician or from a patient advocacy group or medical organization. And, as evidenced by the FDA’s response to the 90 MME proposal from PROP, these comments can make shape policy in a way that protects our patients’ access to critically-needed pain medication. Social media can be a great tool to help build a successful coalition of HPM stakeholders, but time is short – comments must be submitted by Monday, March 5, 2018. To submit comments as an individual, go to www.regulations.gov and enter docket number “CMS-2017-0163” in the search field, then follow the instructions for “submitting a comment.”

Dr. Kollas has provided outpatient palliative care at Orlando Health UFHealth Cancer Center for over 17 years. He first wrote about his personal experiences with chronic illness and pain in a 1997 article in the “On Being a Patient” series in Annals of Internal Medicine. You can find him on Twitter at @ChadDKollas.

Editor's note - The graphic was updated to reflect 2019 changes not 2018 changes as was indicated in the original post. Also, the wording was changed from 'no exemptions' to 'possibly (but not guaranteed).'

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by Stacie Sinclair

(Register for the free webinar here)

There is no disputing that recent events mean a huge shift in the direction of health care in the coming years. Although we’re learning more each day about what programs will stay and what will go, there remains tremendous uncertainty that only time will clarify. Yet in this period of transition, there is at least one major program that the nation’s best health policy minds agree is here to stay: MACRA’s QPP!

WHAT DO THOSE CRAZY ACRONYMS MEAN?
The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) is a bipartisan law that repealed the Sustainable Growth Rate and established a brand-new Quality Payment Program (QPP). The QPP, which goes into effect on January 1, 2017, will accelerate the movement towards payment for value by creating two new clinician payment tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). In the early years of these programs, clinicians participating in MIPS will see positive or negative adjustments to their Medicare Part B billing depending on their “performance”, while clinicians participating in qualifying Advanced APMs will receive a 5% bonus on top of their Part B billing. Ultimately, the track clinicians participate in will depend on many factors, the most important being the amount of RISK their practice accepts.

AND WHY DOES THIS MATTER FOR PALLIATIVE CARE?
First – this is how clinicians will be paid! In years 1 and 2, eligible clinicians (ECs) include physicians, physician assistants, nurse practitioners, clinician nurse specialists, and certified registered nurse anesthetists who bill Medicare Part B for more than $30,000 and see more than 100 Medicare patients annually. And while the implications will vary based on practice size, work environment, participation in an ACO or other APM, etc., the more proactive you are, the more likely you are to be successful!

Second – the emphasis on performance and APMs represents a HUGE opportunity for palliative care. Palliative care is vital to value-based care, as it demonstrably improves quality of care and quality of life for seriously ill patients, and in so doing, helps the health care system avoid unnecessary utilization and spending. At its most basic level, the transition to value means that hospitals and health systems are increasingly on the hook for cost and quality outcomes. So whether you’re an independent program looking to partner, or a team within a large system that deserves more attention, rapid QPP implementation means that there are going to be more leaders looking for “solutions” that we know palliative care can provide!

SO WHAT DO I DO NOW?
Clocking in at over 2,000 pages, there is no question that the final regulations for the QPP are complicated and confusing. But help is on the way! On November 29, 2016, the National Coalition for Hospice and Palliative Care (NCHPC) is sponsoring a FREE WEBINAR to describe provisions of the final rule and next steps (click this link to register). Experts from the Center to Advance Palliative Care (CAPC), the American Academy of Hospice and Palliative Medicine (AAHPM), the Hospice and Palliative Nurses Associations (HPNA), and the HealthCare Chaplaincy Network (HCCN) will be on hand to clarify who will be most affected and activities that palliative care clinicians should be doing right now.

Again, you can register for the webinar by going to this link. And feel free to send me any questions you have in advance – Stacie.Sinclair@mssm.edu!


JUST CAN’T WAIT UNTIL NOVEMBER 29 TO LEARN MORE?
The Centers for Medicare and Medicaid Services (CMS) has developed a fantastic QPP website that walks users step-by-step through the various components of the MIPS and Advanced APM tracks. It includes interactive tools, fact sheets, and other resources, and CMS is providing regular updates as new information becomes available. And if you need just a little more palliative care flavor in your research, be sure to check out the last NCHPC webinar that our all-star team held in early June, describing the basics of the proposed rule.

We look forward to seeing you on November 29!

Stacie Sinclair, MPP, LSWA is the Policy Manager at the Center to Advance Palliative Care (CAPC). If you enjoyed this post, be sure to check out other scintillating takes on health policy and palliative care from the CAPC staff at https://palliativeinpractice.org/health-reform-quarterly/.

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by Phil Rodgers

One of the most valuable things I’ve learned over my 15+ years as a palliative care physician is the importance of gratitude. I’ve learned this from my mentors, my interdisciplinary colleagues, my students, and—most importantly—my patients and their families. Each day that I remember how grateful I am for the privilege of doing what I do, is a better day both for me and for those I work with.

Today I am especially grateful, but for a different reason. Late this afternoon, CMS announced that it will begin reimbursing physicians and qualified practitioners for providing advance care planning (ACP) services to Medicare beneficiaries, starting January 2016. In the proposed Medicare Physician Fee Schedule (MPFS) for 2016, two new CPT codes (99497 and 99498) can be used to bill for more complex advance care planning conversations, whether or not any other services are also provided during the same encounter (detail on pages 246-7). These codes will also allow CMS to track delivery of ACP services, and their impact on care for Medicare beneficiaries.

Many Pallimed readers will be familiar with the growing body of published evidence that ACP leads to care more consistent with individual preferences, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression and lost productivity. But most of you probably didn’t need to read those studies, because you see these deeply valuable, patient- and family-centered outcomes every day in your practices. You already know that capable advance care planning is essential to delivering the best care possible.

So I am grateful that CMS has now recognized this value. And they are in good company: the IOM’s report Dying In America: Improving Quality and Honoring Individual Preferences Near the End of Life cites payment for ACP services among its key recommendations; numerous private insurers and some state Medicaid programs already reimburse practitioners for delivering ACP services; and a broad coalition of ACP supporters—including specialty societies representing the vast majority of US physicians, the AARP, the American Cancer Society LiveSTRONG, the Alzheimer’s Association, the National Council on Aging, and many others—has publicly urged CMS to begin paying CPT codes for ACP services.

I am also grateful to the many HPM professionals and friends who submitted comments to CMS late last year in support of ACP services. Some of you may even have submitted in response to synchronized posts on Pallimed, GeriPal and AAHPM last December—and my gratitude extends to all three host sites for their generosity. Those comments really do matter, and CMS received overwhelmingly positive support for the ACP codes.

There is work yet to be done, as the MPFS proposed rule will not be finalized until late fall, and we’ll need to understand together how and when to use the new codes, so stay tuned in coming weeks and months.

But for today, there is much gratitude. I hope you feel at least some of it with me.

For more info, see the post on GeriPal by Paul Tatum on this same subject, with a different focus.

Phil Rodgers, MD, FAAHPM is co-chair of the American Academy of Hospice and Palliative Medicine Public Policy committee.

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by Christian Sinclair

One of the classic benefits touted by any clinician when describing hospice is bereavement support for the family for 12 months after the death*. What bereavement support looks like depends on the hospice agency. Some are large enough to have departments of specially trained bereavement counselors, and some have a social worker who makes it part of their role.  What they offer may range from phone, email or letter correspondence to individual and group therapy sessions depending on the complexity of the case.  What I have always found interesting is this is not considered part of any insurance or Medicare/Medicaid benefit for someone who dies without hospice in a hospital or nursing home. Anyways, back to hospice and bereavement support...

One of the challenges with studying what hospice does is some of the fundamental parts of it are considered standard of care without ever being tested or analyzed**. Prognostication as eligibility criteria? Yeah, that makes sense for a benefit for dying people, except the science of prognosis has not kept up with the demands of the system for ever-increasing accuracy. Interdisciplinary care required? Sure, that makes sense, but how do we know which team members really work best for each patient, we've never tested it to look for improvements. Bereavement support for families - well now we have a study which may help us understand the impact of this lauded benefit.

Ornstein et al published "Association between Hospice Use and Depressive Symptoms in Surviving Spouses" in JAMA Internal Medicine in May 2015 looked at over 1,000 widowed spouses from the Health and Retirement Study (HRS) data set. 30 percent of the patient-spouse dyads had hospice experience for more than 3 days prior to death. They compared depression scale scores between spouses who had hospice experience and those who had none (to be accurate none, or 1-2 days of hospice). 52% of widowed spouses had more depressive symptoms over time no matter the exposure to hospice. In looking at improvement in depression scale scores over time, more widowed spouses had improvement if they had hospice compared to those who did not, although it was not significantly statistic (28% vs 22% (p=.06) of all spouses; 27% vs 21% (p=.10) for spouses identified as the primary caregiver.)

The most favorable finding for hospice use to help depressive symptoms in surviving spouses was not reported in the abstract results. Of the people who were interviewed (as part of the HRS study), 38% of spouses with hospice experience had improved depressive symptoms, a statistically significant (p=.01) improvement over those who had no hospice exposure (26%). For any of you odds ratio fans, that came out to an OR of 2.15!

Most media reports gave pretty favorable headlines to this study, which I think is close enough for public knowledge and understanding. Can you use this research in your hospice 101 presentation? Sure. Can you make some nifty graphics to share online? Sure. Can we use this information to help us better structure interventions for the bereaved family? Maybe.

First, while this is a strong study in terms of numbers, matching interventions with controls, and being somewhat objective to the intervention of hospice***, the study was unable to tell what bereavement interventions occurred and therefore it is difficult to tell what interventions are helpful and which have no effect or potentially harm. So this is not a full ringing endorsement of bereavement services, but rather hospice use.

As mentioned earlier on close examination it is not truly hospice for 3 or more days vs no hospice. The true selection criteria were hospice for 3 or more days vs 0,1,or 2 days of hospice. There isn't a solid explanation in the article for this awkward choice of group selection, and the only place it is mentioned is in the footnotes of Table 4. The authors rightfully note hospice enrollment for even 1 or 2 allows for access to bereavement services, so theoretically we are not testing two different groups.

So, overall this study (despite the confounding selection choice) does help demonstrate hospice use possibly leads to better depressive symptoms, but we need to look to other studies for a more accurate depiction of the impact of bereavement services on spousal and family coping over time. This is an area of study which would benefit from a good mix of qualitative and quantitative research,

Christian Sinclair, MD, FAAHPM is a palliative care doctor at University of Kansas Medical Center, and has been a hospice medical director for 11 years. He has witnessed the good works of bereavement counselors. 

*The regulations say up to a year, but nearly every hospice offers about 13 months of support to get people past the anniversary of the death.

** You know what else became standard of care without being tested or analyzed? PEG tubes in advanced cognitive impairment. It just 'made sense.' Only recently have we started to get the evidence published that it does more harm than good.

***  The depression scale was part of routine screening, not some asking you to enroll in a study of how hospice affects depressive symptoms in surviving spouses.

Ornstein KA, Aldridge MD, Garrido MM, Gorges R, Meier DE, & Kelley AS (2015). Association Between Hospice Use and Depressive Symptoms in Surviving Spouses. JAMA Internal Medicine PMID: 26009859

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Kristina Newport MD (@kbnewport) practices Hospice and Palliative Medicine in Lancaster, PA where she also spends time running after her children, 4 and 6.

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First reported by Modern Healthcare, CMS (Medicare) has proposed a 1.3% rate increase for hospice organizations for FY 2016, which is a just under the 1.4% increase for FY 2015. This comes from a un-published proposed rule that also has some other provisions including clarification on diagnosis reporting, and a review of data that may inform hospice payment reform based on increased service intensity in the last seven days of a beneficiary's life. The official release date is May 5th, with a 60 day comment period to follow.

There are some really insightful charts and graphs in this report to look at diagnosis, cost and use patterns.  For example, this one on Medicare daily costs in the 180 days prior to hospice admissions vs the length of stay on hospice. Many in the field recognize that people recently on hemodialysis may get hospice very late, and that people with dementia are on hospice longer.  But from a systems standpoint, I never thought about how CMS may see these pre/post-hospice costs. I drew an extra red line on the graph to approximate the daily hospice reimbursement rate of $153 (FY 2013). So looking briefly at this graph, one may make an argument that hospice care may be (slightly) more expensive than traditional medical care at the end of life. Important to understand if this is how CMS and policy makers are looking at it.

We welcome discussion here about what you see as good and bad about this proposed rule and hope to have further analysis of the document as we get time to review it (volunteers needed). In addition, we hope that you fulfill your role as hospice and palliative care advocates and submit a comment* to CMS on this proposed rule; even if it is as simple as "Continue support for the Medicare Hospice Benefit!" But we know you are more creative and passionate and will come up with something much more substantial!

*comments are not yet open since the rule is not officially published. But no worries, we will remind you when it is time along with highlighting a few of the areas you may be most interested in.

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by Phil Rodgers, MD, FAAHPM, Co-Chair, AAHPM Public Policy Committee

(The following is part of a three-post progressive blog about advance care planning, prompted by the Centers for Medicare and Medicaid (CMS) decision not to pay for the new “complex advance care planning” codes in this year's Medicare Physician Fee Schedule. Now is the time to tell CMS why you support reimbursement for these important services! The agency is accepting public comments through Dec. 30 —it’s easy to submit comments online!

Please also see AAHPM Public Policy Committee Co-chair Gregg VandeKieft's update on how key organizations are collaborating beyond AAHPM to make Advance Care Planning efforts succeed. And don't miss out on AAHPM State Policy Issues Working Group Chair Paul Tatum’s GeriPal post where he makes the case that it’s time for advance care planning to become routine for patients with serious illness. - Ed.)

Late on October 31st, the Center for Medicare and Medicaid Services (CMS) published the 1185-page 2015 Medicare Physician Fee Schedule (MPFS). What is the MPFS? If you don’t know, don’t worry—the majority of Americans (including many health care professionals) have no idea this document exists, and until recently I was among them.

In short, the MPFS lays out how Medicare intends to reimburse ‘practitioner’ services for the coming year. ‘Practitioners’ include physicians, nurse practitioners, physician assistants and other professionals who provide ‘qualifying’ services to Medicare beneficiaries. These services are most often described by Current Procedural Terminology (CPT) codes, and valued through Resource-Based Relative Value Units (known as RBRVUs or just RVUs).

I have been fortunate enough to be supported over the past year by the American Academy of Hospice and Palliative Medicine (AAHPM) to serve as their advisor to the AMA’s Relative Value Scale Update Committee or ‘RUC’, which recommends RVU values to CMS for each and every CPT code. In this role, I’ve been able to advocate for the work that HPM professionals do every day, in the process by which those services are described for CMS to determine how much they will pay for them. In other words, HPM has a voice in the process (or ‘seat at the table’, choose your favorite metaphor), in helping CMS understand what it takes to deliver high-quality care for patients with serious illness.

Why should we care? Medicare fee-for-service covers 33 million older and disabled Americans, and in most markets is THE largest payer of hospice and palliative medicine practitioner services. It also often sets payment benchmarks for commercial payers (including Medicare Advantage plans, which cover an additional 14+ million beneficiaries). As a result, the MPFS tells us how and how much HPM practitioners will be paid for a large part of the work they do. So, dense and obtuse as this all may seem, it matters.

The 2015 MPFS matters even more to HPM providers, as it (for the first time) includes Advance Care Planning (ACP) services. These services are described as “…the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; face-to-face with the patient, family member(s), and/or surrogate.” While the descriptor mentions ‘form completion’, these codes really cover more substantive discussions about goals of care, treatment options, values and preferences.

The CPT and RUC processes have developed and valued two codes for these ACP services: 99497 (first 30 minutes, valued at 1.50 RVUs) and 99498 (each additional 30 minutes, valued at 1.40 RVUs). They can be billed in addition to Evaluation and Management (E/M) codes, reflecting the ‘separate and identifiable’ (in CPT lingo) nature of more complex ACP discussions.

The ACP codes have a backstory (see Pam Belluck’s excellent piece in the Aug 30 New York Times) that brushes up against everything from ‘death panels’ to a growing number of commercial insurers and Medicaid programs who have already begun to pay for ACP services. In the 2015 MPFS, CMS acknowledged both codes, but stopped short of authorizing Medicare payment for them for 2015 (more on that below).

I want to pause here to acknowledge two things about these codes. First, it is a major step forward even to describe and value advance care planning services, the enormous impact of which is demonstrated by a growing body of research and the daily work of health care professionals who perform them (including many Pallimed readers). Yes, it’s many years too late and still part of a system of many misaligned financial incentives, but it’s an important start. Second, and more importantly, is that support for ACP services is broad and deep within the physician community. The most striking part of my experience working on these codes has been the coalition that formed to advocate for them.

The American Geriatrics Society − which only received a permanent seat on the RUC in early 2012 ­– has taken the lead to organize this coalition, providing staff support for stakeholder societies (including AAHPM) to join forces and advocate for the ACP codes through the RUC process, and in joint communications and face-to-face meetings with CMS. There are big players involved – like the American College of Physicians and the American Academy of Family Physicians which together represent over 250,000 physicians – along with specialty societies like AMDA – The Society for Post-Acute and Long-Term Care Medicine, the American Academy of Home Care Medicine, the American Academy of Neurology , and the American Thoracic Society. The physician leaders from these groups continue to speak eloquently and passionately about caring for patients with serious illness, and specifically about the necessity of high-quality advance care planning.

Now it’s your turn. While Medicare did not agree to start reimbursing the advance care planning codes for 2015, they did signal openness to reimburse them in the future, and invited comments until December 30. Individual comments really do matter to CMS: staffers read every submission, and individual comments are actually cited throughout the MPFS as rationale for payment decisions.

So, it’s time to tell CMS why you support reimbursement for advance care planning services. You do not need to be a physician or even a clinician to comment . A couple of things to consider when writing your comments:

• Tell why you think it’s important to pay for ACP services through a specific mechanism. CMS has suggested that it believes Medicare already pays for ACP services through the Evaluation and Management (E/M) and extended service codes.
• Tell them about the unique value of advance care planning, and how it is ‘separately and identifiably’ necessary in addition to all other services (medical therapy, symptom management, etc.).
• Be specific, be yourself, and write about what you know. It’s OK to reference the literature about ACP services and palliative care, the IOM report, the importance of tracking the frequency ACP is performed, the needs of an older and sicker society etc., but it’s more powerful to speak from personal experience. 
• Tell patient stories that illuminate a connection between high quality advance care planning and better care for your patients. Every HPM professional I know has dozens if not hundreds such stories.  

Now is the time to tell them.

Comments are open until December 30 and can be submitted online.

Don't forget to check out the other two blog posts in our progressive blog party! Click the images below.

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Ziad Obermeyer et. al published a large, rigorous study in JAMA this month (Open Access!) that provides cost and aggressiveness data to support the use of hospice for poor-prognosis cancer patients who stop cancer related treatments. The bottom line of the study is:

The choice to enroll in hospice definitely decreases cost and aggressiveness of care in patients with poor-prognosis cancer who are no longer receiving disease directed therapies.

This finding is consistent with Kelley et al’s 2013 study of hospice length of stay showing that hospice enrollment, for all diagnoses, saved Medicare dollars during all length of stay (LOS) periods measured, with the greatest benefit in patients enrolled 8-30 days($5,040-6,430). All LOS groups also had associated decrease in hospitalizations, ICU days, hospital deaths and hospital readmissions.

The Obermeyer study significantly confirms that this benefit also exists for hospice utilization in advanced cancer. So let’s break it down so that we can be sure to use/apply it appropriately:

Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer

Background: People with cancer historically have been the largest recipients of the Medicare Hospice Benefit (per NHPCO, 37% of all beneficiaries in 2013) but their LOS is shorter than the general population, having the highest rates of hospice stay less than 3 days. Short hospice LOS and increased intensity of care outside of hospice spurred this research group to explore health care utilization and costs in the poor-prognosis cancer population.

Population:

• Medicare fee-for-service beneficiaries with poor-prognosis malignancies who died in 2011 after a full year of Medicare coverage were included.
• ICD codes for pancreatic, lung, brain, metastatic or ill-defined malignancies, or hematologic malignancies that are relapsed or not in remission.
• Large study: 36,330 patients in the final matched cohort from an initial sample 86,851 patients.

Matching: (see the study for the complex details- this is significantly simplified)

• Poor-prognosis cancer patients who enrolled with hospice were matched with those who did not
• Coarsened exact matching variables: Place of residence, age, sex, time from first poor-prognosis cancer diagnosis to death
• Compared utilization before and after hospice to try to determine what may have happened if the patient had chosen hospice.
• Matching did not include: Objective performance status, caregiver status, availability of hospice or other palliative care services
• Pairs were not included if either member of the pair utilized cancer directed treatment (defined as chemotherapy or cancer related surgery) during the exposure period (so, only people who stopped all cancer directed treatments were included in the study!)

Outcome Measures:

Primary: Health care utilization during hospice enrollment or the equivalent period of time in non-hospice patients, including hospitalization and ICU frequency, number of inpatient procedures and deaths in hospital or skilled nursing facility. Did not include death in assisted living or inpatient hospice.

Secondary: Total cost, including beneficiary payments, Medicare payments and third party payments for inpatient care, hospice costs, physician costs, non-institutional provider payments. Did not include medications, personal care or non-Medicare paid services.

Results:

• Median time until death after diagnosis of poor-prognosis cancer was 13 months.
• 60% of patients received hospice care.
• Median hospice LOS 11 days, less than 6% had a LOS of more than 6 months.
• Patients who chose hospice
• • Spent less time in the hospital
  • Spent less time in the ICU
  • Had less inpatient procedures billed.
• Death in a facility (hospital or skilled nursing facility) decreased: 14% versus 74%
• Cost of care in the last week of life decreased: $8,421 versus $3,892, - more than 50% difference
• Costs were decreased in all hospice LOS periods except for the 2% of beneficiaries enrolled more than 1 year
• The greatest cost savings: LOS 5-8 weeks which decreased cumulative costs by 24%
• Cumulative cost for the last year of life* decreased: $71,517 versus $62,819, a 12% difference
• • *This is difficult to interpret since patients had varied hospice lengths of stay, with many patients enrolled in hospice only 3 days prior to death, this number hardly seems reflective of a hospice effect. And some of them were not even diagnosed with their cancer for the full year, resulting in spuriously lower costs.

Author's Conclusion:

In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care, compared with matched control patients not receiving hospice care, had significantly lower rates of hospitalization, intensive care unit admission and invasive procedures at the end of life, along with significantly lower health care expenditures during the last year of life.

Concerns/Thoughts:
Factors that influence patients’ decision to enroll in hospice services were not addressed. They may include:

• Caregiver availability - Prior to the exposure period, hospice patients in the sample used more home health and non-hospice patients used more skilled nursing facilities. I would argue the increased use of skilled nursing may reflect inadequate resources for in home care. Patients in this study, like many patients I’ve care for, may have been faced with the decision to enroll in hospice OR get their skilled nursing home stay paid through Medicare. If care giving is an issue, they may have chosen ECF instead of hospice. This increases costs and moves site of death to the ECF. If there were better payment options for in-home custodial care, patients may choose to stay at home, with hospice, instead.
• Hospice/palliative care availability - we don’t know why patients did not choose hospice. They were all clearly eligible. Since available services/facilities were not described, we do not know if the availability of hospice & palliative care influenced the propensity to enroll in hospice. This may be particularly relevant to patients living in a rural community where there is greater variability in services despite the study attempt to match place of residence.
• Data from personal care or inpatient hospice facilities was not available - Therefore this data may miss significant caregiving costs and frequency of deaths in facilities other than hospital or ECF.

Other interesting findings:

Patients who were selected for the study, who did not received cancer directed therapies during the exposure period, lived in zip codes with higher incomes and had a shorter median time from diagnosis to death. This could be further investigated- maybe these factors influence patients’ decisions to stop cancer directed treatments?

My Conclusion:

Care for people who chose hospice after stopping cancer treatments cost 12-50% less than care for people who didn’t and less of them died in facilities, despite median hospice LOS of less than 2 weeks.

Other Takeaway Points:

• Although cancer comprises the largest group of hospice diagnoses (37%), people with poor-prognosis cancers have shorter hospice length of stays than overall population (11 days versus 19 days)
• When sharing this study with others, don’t forget that this cost-avoidance occurs in the setting of care that is proven to increase patient and family satisfaction, decreased symptom distress and improved outcomes for caregivers. (Even the most curmudgeonly administrator likes that combination!)
• These data cannot be applied to:
• • Young patients who have private insurance
  • Patients who are receiving any chemotherapy or cancer related surgeries, including those who receive oral targeted agents or who (presumably) have palliative surgeries for bowel obstruction, cord compression etc.
• This study cannot definitively separate whether the hospice services, or the propensity to choose hospice services has the greater effect, so we don’t know for sure if hospice in a “Concurrent Care” model would have similar results.
• Although consistent with other studies, these findings cannot be applied to non-cancer patients

Studies like this are very difficult to do and cannot control all variables, so kudos and thank you to all of those involved in this project for contributing such great data to the field!

Image Credit: US Postal Service
Image Credit: Unknown infographic from Pinterest

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by Dale Lupu

How many times has a friend, a relative or a colleague asked me to recommend a good hospice in Reno or Redding or Rockford and I was flummoxed. Even if I knew the medical director or the executive director from work on national committees and thought he or she was a great, what did I really know about the quality of service provided by their hospice? I often wished I could have access to the kind of data I typically review when consulting with a hospice - their length of stay, proportion of patients living in a nursing home, proportion of patients discharged alive, readiness to provide continuous care, robustness of the on-call service, etc.

Now, at least some of that information is available on-line through a website developed by the Washington Post. The key information in the new Consumer Guide to Hospice is taken from Medicare cost reports and "other sources." One can see the size of the hospice, age, ownership type, amount of continuous care or general inpatient care provided, and spending per day on therapy, doctors, and nursing.  The database also reports a hospice's "profit" per day, a label I find highly misleading (more on that below).

Is this information helpful?

In a limited way, yes. I would advise people to look first at accreditation status. Only 40% of hospices are accredited, and I would always lean towards an accredited program when available. Although accreditation tends to focus more on structure and processes than on outcomes, a program that has been accredited has had objective outside reviewers who have given it a stamp of approval. That speaks to a program's willingness to open itself to review and, hopefully, improvement.

Next, focus on size and age of the hospice. As in almost every other part of medicine, practice is linked to higher quality. Experience - gained over time and gained over a number of cases, usually helps build both individual clinician expertise and organizational/team expertise. Very new and very small hospices are unlikely to have the breadth of experience and the depth of resources to assist with challenging or unusual circumstances. Unless I had a specific reason to know that a very small or very new hospice had a service or skill that was needed (such as a new pediatric service or a new hospice residence), I would stick with hospices with experience of at least 5 years (10 years is even better) and volume of at least 80 patients per day. Not always possible in a rural area - but rural areas may not offer a choice in any case.

Third, I would advise people to look at the proportion of "crisis care" - which I surmise was calculated as the number of continuous care and general inpatient days as a proportion of total days. (I cannot find specific methods notes explaining exactly how items were calculated - a drawback to the site.) The limitation in the "crisis care" number reported is it doesn't distinguish between continuous care at home and general inpatient care in a facility. A hospice which handles almost all crises in a contract hospital bed is not the same as one able to put in continuous care nursing in the home with a few hours notice - but patient's may strongly prefer one over another. Still, I'd want to pick a hospice that demonstrated it had SOME capacity that it used for crises care, rather than picking from the 14% of hospices that provided no crises care.

Third, I'd look at the "live discharge" rate. The Post justifies this number saying that large number of people leaving a hospice may indicate they are unhappy with the care and services. Maybe. More likely it represents a hospice had a very (maybe overly) open admission policy, taking people too early and too "healthy" and then discharging them. I would actually select hospices that had live discharge rates in the 10% to 20% range. Too few live discharges likely means the hospice is too tight and guarded in who they accept, and not willing to bend flexibly to each patient and family's needs. But too high a discharge rate - let's say over about one third - makes me uncomfortable too. Stay in the middle on this indicator.

Fourth - I would advise NOT looking at the $ per day. The data likely comes from the Medicare Hospice Cost Reports, which have all kinds of issues in how data is reported, especially when hospices run their own inpatient units. The so called "profit" is especially misleading. I can't tell exactly how the Washington Post calculated the number - but if, as I guess, it is everything left over after "allowable" Medicare costs, it is in no way all "profit" for a hospice. Recall, hospices are required to provide bereavement services without Medicare reimbursement. Many hospices plow money left over after nursing and doctor and therapy costs into community bereavement services, extensive community education, bridge programs, or other community services. The "profit" number doesn't give any indication whether these dollars are truly "profit" being returned to shareholders, reserves begin saved for a rainy day, or carefully husbanded resources that fund additional community services. As interesting as it is, I'd ignore that information when choosing a hospice.

The Consumer Guide allows you to filter by ownership status at the very start of a query, which seems to imply that ownership status ought to be part of one's consideration. But I don't find ownership status to be a very useful indicator. It's true that a lot of Medpac's recent policy analysis has focused on differences between not-for-profit and for-profit providers, and that some concerning trends are associated with for-profit providers.  But in my experience there are both good and not-so-good providers in both groups, and ownership status is not nearly as helpful in distinguishing between them as the other factors mentioned above.

Finally - I would advise supplementing the information in the Consumer Guide with careful telephone screening of any hospice being considered. I like the list of 16 questions to ask on the website of the American Hospice Foundation (disclosure: I was on the AHF board for many years.)

Many in our community have been upset at the way that the ongoing Washington Post series has emphasized problems in hospice care. I agree that those problems are not the rule - but we also can't ignore them. Giving consumers - and us, the supposed experts - the information to begin to sort out who is operating way outside of the norm - is a helpful step. I applaud the Washington Post for making this information accessible.

PS. Make sure your hospice checks - and corrects, if necessary - the information displayed about it. We have already heard from some organizations who noticed errant information for their site.

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(If you missed Part 1 or Part 2, click on the links. If you don’t have time, here is the quick summary. The Washington Post published an article December 26th, 2013 claiming hospice care was taking billions from Medicare presumably in waste and fraud. This series offers a critical review debunking the claims and offering a more insightful view of the challenges hospices face. Today Dr. Scott tackles some statistics and the way forward - Ed. Sinclair)

One of the consistent errors made by people commenting on this story, either in the comments sections or on social media, is the failure to understand the difference between estimated marginal life expectancy and actual marginal life span. The hospice regulations require two physicians to certify that the patient’s life expectancy is less than or equal to six months if the disease/illness runs its normal course, given their current condition and taking into account any decisions made by the patient/family to forego potential treatments. Many are erroneously confusing life span and life expectancy.

If the regulations instead required two physicians to certify that the patient’s actual marginal life span will be six months or less, then these commenters would be right. In that case, patients who lived longer than six months would be evidence of error. You would probably allow a few of them, as an acceptable error rate. One commenter argued that patients who lived longer than six months should be considered analogous to the patients with suspected appendicitis, had surgery, yet turned out to have a normal appendix. You accept a percentage of surgeries for normal appendixes in order to minimize the risk for missing abnormal appendixes. (This was a more common idea prior to the more extensive use of imaging to guide the surgery decision.) This is an inappropriate analogy. Starting an appendectomy for someone with a normal appendix is a mistake. No benefit accrues to the patient. A patient who lives for seven months after being admitted to hospice is not necessarily a mistake. It does not follow that the original certification was wrong. In fact, it was probably right. At worst it was likely to be borderline. Half the patients in a group with a median life expectancy of six months will live longer than six months. Those who do still received a benefit from being on hospice. And Medicare saved money because they were on hospice.

Since the regulations stipulate life expectancy, it would be useful to think about what a frequency distribution curve would look like for a set of patients with a median life expectancy of less than six months. It would be a positively-skewed distribution. It bunches up at the left side, since it is bounded at zero days. Patients cannot die sooner than right now. It tails off to the right, with what are called outliers. The flatter the curve, the further out that tail will go. For non-cancer diagnoses that are harder to prognosticate, the curve is flatter, with more outliers and more extreme values for outliers. This is not indicative of fraud. Claiming it is represents a misunderstanding of the mathematics involved.


Hospices have traditionally enrolled patients with life expectancies considerably less than six months. It has been a concerted effort to try to enroll patients sooner. This has been encouraged (even by MedPAC) as a way to save Medicare a great deal of (more) money. Consider the “ideal” situation, where most patients were enrolled when they reached a median life-expectancy of six months. In this case, half of the patients would have a life-expectancy greater than six months. There would (for most diagnoses) be outliers that stretched into years. A hospice that succeeds in enrolling patients earlier in the process—closer to the six month estimate – will end up with more patients who live 7+ months. This is simply the mathematical consequence of a positively-skewed distribution, which is what a life-expectancy distribution for hospice patients looks like. (The stats geeks reading this, who are already seething about my over-simplifications here, may be thinking that the distribution is actually bi-modal. I hear you. I feel your pain. But I’m not going to try to go into that idea now.)

Currently, when you see differences in the MEAN length of stay for for-profit hospices compared to not-for-profit hospices, it is because of differences in the mix between cancer and non-cancer diagnoses. The MEDIAN length of stay shows no difference. Cancer has a more predictable course. Its life-expectancy distribution curves are narrower. Non-cancer diagnoses have flatter curves, with more skew to the right. The outliers are further away from the median. The more of these patients enrolled, the more extreme outliers you expect, and the further you pull the mean away from the median. The authors admitted that NHPCO had explained this to them, but then ignored that explanation (or didn’t understand it) when they asserted that “the growth in the average duration of hospice care stems less from the decline in the proportion of cancer patients than from another trend. Patients who are suffering from a non-cancer ailment began staying longer on hospice: Their average stay in hospice care grew from six weeks to almost 11 weeks on average between 2002 and 2012.“ Do note that the authors are using an increase in average length of stay to 11 weeks as part of their argument. 11 weeks is less than three months. The Medicare Hospice benefit asks us to certify patients with an expected life expectancy of six months or less, more than twice that average. Any argument that seriously uses an 11 week mean length of stay as an argument that an unacceptably high proportion of these patients really had a life expectancy of greater than six months is prima facie a bad argument.

Others commented that non-death discharges should be viewed as errors as well. While I agree that the very high percentage of non-death discharges is worth looking into further, I vehemently disagree with the idea that non-death discharges should in general be considered failures, wastes of money, or fraud. There are many reasons for non-death discharges. Those of us who are hospice providers consider many of these reasons to be successes rather than failures.

Take the cancer patient who would have wanted to try chemotherapy but whose oncologist feels that performance status is too poor and burden outweighs benefit. This patient can enroll in hospice. Patients often feel better, improve, after enrolling in hospice. The extra help at home. The excellent symptom management. The optimization of medication regimen (which often includes discontinuing cholesterol, blood pressure, and diabetes medications that don’t have a net benefit vs burden). All of these things can contribute to a patient improving. Some of these patients will improve sufficiently that they are candidates for chemotherapy. We happily discharge these patients, knowing that we helped them and that they are not getting the treatment that is consistent with their goals. We call these patients “hospice graduates”.

The same sort of improvement can be seen in non-cancer patients as well. Dementia patients are a prime example of this. We see improvements for the same reasons: more care at home, better symptom management, optimization of medication regimens. Now these patients improve enough that they no longer fit the category of “life-expectancy less than six months”. We discharge these patients, but LESS happily. We are happy that they improved, but we’d like to keep them, since we think our interventions led to the improvements. For Alzheimer’s disease, these patients are STILL DYING. They still have a terminal illness. They just have a life expectancy estimate that exceeds six months. Most of us wish we didn’t have to discharge these patients. We discharge them because we play by the rules. A rational, well-designed Medicare hospice policy wouldn’t require us to do so. Note that the scrutiny placed on hospices for these patients has actually led to more patients being discharged (as hospices fear they will be challenged on these admits). If you are more interested in scoring rhetorical points than you are in having an honest discussion, then you can use this “increase in live discharges” to claim this proves that hospices were doing something wrong all along.

The authors inappropriately used mean as the measure of central tendency when discussing length of stay. Hospice length of stay data graphs out as a positively-skewed distribution. The honest measure of central tendency to use with such a distribution is the median. Use of the mean instead is considered to be deceptive. It will be listed in any handbook of “How to Lie with Statistics”. This is basic, intro-level stuff. There are only two possibilities. Either the authors knew that mean was inappropriate or they didn’t. If they didn’t know that using the mean is inappropriate, then they are not qualified to be incorporating such statistics into their articles without seeking help. (Their editor should have caught this. If neither the editor nor the authors were sufficiently familiar with intro-level statistics, they should have asked a starving adjunct professor teaching at the local community college to help them out.) If they DID know that mean was inappropriate and chose to use it anyway, then they are guilty of deception, of believing that their narrative was so important that the means justified the ends when trying to convince others. Including both mean and median would be acceptable reporting (and is what both NHPCO and MedPAC do).

The mean length of stay did increase between 2000 and 2011, but didn’t substantially between 2009, 2010, and 2011. Between 2009 and 2010, both the mean and median length of stay DECREASED. The median (50th percentile) length of service in 2010 was 19.7 days, a decrease from 21.1 days in 2009. The average length of service dropped to 67.4 days in 2010 from 69 days in 2009. Comparing 2000 to 2011, the average length of stay increased from 54 to 86, but the median stayed the same at 17 days. Between 2000 and 2011, total number of hospice patients increased from 534,000 to 1,219,000.

For access to the primary data:
http://www.medpac.gov/chapters/Mar13_Ch12.pdf
http://www.nhpco.org/press-room/press-releases/research-published-jama
http://www.nhpco.org/press-room/press-releases/hospice-facts-figures
And for annual stats back to 2006 see this Pallimed post.

Thus the same number of short stay and long stay patients are being added. Long stay patients defray the costs of taking care of short stay patients. And long stay patients enrolled in hospice still save Medicare money, even the outliers.

The authors used flawed MedPAC data when discussing profit margin. MedPAC itself admits that their data is inaccurate and incomplete. It fails to include costs for federally mandated volunteer (for at least 5% of patient care hours) and bereavement services (for at least 13 months after patient death). These are real costs to hospices, and the data ignores them.

From this NHPCO press release:

“The discrepancy in the numbers is an indication of a change in the calculation methodology, by excluding the costs of delivering statutorily mandated services, rather than pointing to the fact that hospice margins are actually shrinking. For MedPAC to recommend countering an erroneous growth in hospice margins by reducing the annual inflationary adjustment is absurd and potentially devastating to the hospice community”.

Finally, let me reiterate that I actually agree that there is some fraud by hospice firms. There is some fraud in all situations involving companies with a profit motive. The authors did not make their case that it is widespread. They didn’t come close to making their case that hospice firms are costing Medicare any money at all, much less “draining billions”. They pointed out that some lawsuits are pending. I’d point out that these represent potential problems and not yet proven ones. Judges have ruled against Medicare and for hospice organziations in the past in hospice CAP payment cases.

Despite having grossly exaggerated the cost to Medicare, falsely suggested that discharged patients weren’t actually dying, and deceptively used statistics to advance their narrative, the authors did raise some important points as well. They described some fairly unpleasant recruitment tactics. I consider some of these tactics to be unethical. I would not want to be involved with a hospice that used them. The recruitment bonuses are particularly galling. Note that the NHPCO actually considers these to be unethical as well. They are not, however, against the current rules, nor are they illegal. And they are the same sorts of things that happen at businesses around the country. I want hospices to be better than businesses around the country. My gut feeling is that hospices ARE in general better than businesses around the country. (I think that this stems partly from the fact that hospice team members, current blogger excepted, in general are very nice people.) But we can’t expect all hospice firms to be better than other corporations just because it’s the nice thing to do. With money involved, it isn’t a surprise that some companies aren’t. If Medicare would like to write some better rules, I’d be among those cheering.

Other posts in this series:
Part 1 (Tue): Debunking the hyperbolic headlines
Part 2 (Wed): Did these hospices enroll patients inappropriately? Do for-profit and not-for profit hospices differ?
Part 3 (Thu): Digging into the statistics and the way forward

Bruce Scott (@skipbidder) is an academic physician in Ohio, fellowship-trained and board certified in Geriatrics and in Hospice and Palliative Medicine. His hobbies include boardgaming, cooking, and pedantry.