A new Medicare pilot program will make it easier for patients to access some hospice benefits without giving up standard medical treatment for a terminal disease. It is an important step towards building a health system that fully integrates social, spiritual, and palliative care such as pain management with health care. But it doesn’t get all the way there.
Today, fewer than half of all Medicare recipients ever enroll in hospice, and those that do often wait until just a few days before they die. While we are still trying to understand why, one reason may be that people feel they are being forced to give up medical treatment in exchange for hospice services. This pilot could begin to change that.
More than 140 hospices around the country will participate in the five-year experiment, called Care Choices. For patients who choose to enroll, hospice will provide wrap-around services such as nursing, social work, respite care, and nutritional and spiritual support to complement regular medical care, including curative treatments such as chemotherapy.
The pilot will be optional. Patients can still participate in traditional hospice. The new program will be limited to people with advanced cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure, and HIV/AIDS who are otherwise eligible for hospice.
In effect, the pilot will add hospice to a care team that may also include a primary care physician and one or more specialists. It has the potential to fill an enormous gap in the care of very ill patients by providing palliative services such as pain management to many people living in the community. Today, Medicare will pay for palliative care only for people who are in hospitals or nursing facilities or who are in hospice care. To put it another way, if you are not dying, Medicare won’t provide comfort care at home. Under this new pilot, it will.
Half the participating hospices will begin offering the new services on Jan. 1. The rest will start in 2018. The federal Medicare program estimates that about 150,000 people will eventually enroll.
The Care Choice concept is not entirely new. There are already non-medical hospices that provide volunteer services for those still getting aggressive treatment. And open hospices provide both comfort care and medical treatment. But Medicare doesn’t pay for these options.
Under the new pilot, Medicare will pay hospice $400 per-patient-per-month for a skinnied-down version of its services. Hospitals and non-hospice physicians will bill Medicare for the services they provide, just as they do for non-hospice patients today. Similarly, Medicare will pay as usual for durable medical equipment such as wheelchairs or for drugs (if you have Medicare Part D benefits).
However, the program still falls short of a fully-integrated care model for people with severe illness who want to continue curative treatment.
In traditional hospice, all medical care, social services, medications, and the like are fully coordinated through a team usually led by a nurse with special end-of-life care training. And hospice provides all of these services at no cost to patients.
When hospice works as it should, a patient can get the care she needs with a single phone call. But Care Choice patients won’t have access to that one-stop shopping. They’ll still have to navigate between hospice care and traditional fee-for-service medicine. While they may have case managers to help, they’ll still risk falling between the care cracks.
For this model to succeed, hospice providers, home care agencies, primary care physicians, and specialists will have to work closely and cooperatively on critical issues such as pain management or after-hours care. In some cases, hospitals and nursing facilities will also be involved. Until now, the fee-for-service health system has struggled mightily to achieve that level of coordination.
Still, this experiment is extremely important step. People with terminal illnesses will be able to access some hospice services while getting regular medical treatment for their terminal illness. They’ll be able to opt out of aggressive treatment on their own terms. And the pilot will give us all a chance to learn whether this model can improve the quality of end-of-life care and, perhaps, save Medicare money.
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