Volume to Value–Will this change also impact hospice?
Value based reimbursement is actively making its way into various healthcare environments. By December of 2018, Medicare aspires 50% of reimbursements will be connected to value. 1 Hospice agencies may be ahead of the game, as studies show increased family satisfaction with care and quality of dying with hospice use. 2,3 And, starting in 2015, hospices were required to initiate the “Consumer Assessment of Healthcare Providers and Systems hospice survey,” which includes questions about quality performance. 4
Should hospice care be one sector of healthcare that is only non-profit?
I talked with a number of experts in the field of hospice care and management, and all agreed that dying people should not be vulnerable to profiteering. Many agree that the rest of healthcare should remain capitalistic, and include private and public ownership.
The emergence and continued rise of for-profit hospices in the United States has garnered much attention. Of primary concern are the claims of “cherry picking” patients—for-profit hospices have been found to have a significantly higher number of patients on their census known for having longer lengths of stay, which leads to higher reimbursement from the Medicare Hospice Benefit (MHB). 5 Certainly, non-profit hospices also need to be held accountable, but this is about the intention. Should care of the seriously ill and dying center around making a profit?
Increasing access to hospice and an aging population
APRNs ability to sign terminal certifications for hospice eligibility has potential to increase the number of people receiving hospice services. 6 Increasing access to hospice care leads to increased cost to Medicare via the MHB.
And with an aging population, and increasing numbers of people living with dementia, which is the most expensive diagnosis for hospice care…
“Average per-person hospice care payments for beneficiaries with Alzheimer’s disease and other dementias were 10 times as great as for all other Medicare beneficiaries ($1,976 per person compared with $193 per person).” 7, p. 56
…we foresee a financial crisis ahead for Medicare even without increased access to hospice.
So, How Can We Sustain?
Currently, there is a “Medicare Annual Aggregate Cap” for hospices, and if exceeded, the agency must give money back to Medicare. 5 This cap and/or the daily patient reimbursement from MHB could be reduced to further save Medicare dollars.
Innovation through concurrent care models integrating palliative and hospice care philosophies hold promise for saving money and improving quality care.8 The stakeholders involved (patients/families, healthcare providers & administrators, insurance companies & other payers, policy makers) will need to come to some agreement for this care model to succeed. 9
Presently, palliative care services receive inadequate reimbursement (and no reimbursement for some of the specialized interdisciplinary services, i.e. social workers and chaplains). 9 However, hospitals are saving significant amounts of money with inpatient palliative services, even when the cost of the entire palliative care program is subtracted. 9, 10
“This study found that palliative care consultation was associated with a reduction in direct hospital costs of almost $1700 per admission ($174 per day) for live discharges and of almost $5000 per admission ($374 per day) for patients who died.” 10, p. 1789
And, there is the hope that value based care will save money (i.e. less tests, expensive and aggressive treatments, and medications ) and allow clinicians more time with patients. This may be a double-edged sword. If clinicians, for example, decrease daily patient contacts from 30 to 15, who will provide care to the other 15? Yet, if things do not change, excellent providers may leave. I just talked with a physician friend who is planning for early retirement—she lost her passion for medicine because of a system that demands a high quantity of documentation and limited time to spend with patients. I have heard this similar response from many nurses.
APRNs in Hospice and Palliative Care—Part of the Solution
“Multiple studies have shown that nurse practitioners provide high-value primary care, comparable in quality to that of physicians.” 11,12 Palliative care physicians are already in short supply, and this shortage is anticipated to worsen. 13 APRNs (currently limited to nurse practitioners (NPs) and clinical nurse specialists (CNSs)) can achieve certification as “Advanced Certified Hospice and Palliative Nurses” through the “National Board of Certification for Hospice and Palliative Nurses.” 14 Thus, supporting APRNs to function independently at their highest scope of practice, within a model of interdisciplinary teamwork, will assist in solving the percolating, soon to boil over, problem of inadequate numbers of practitioners to meet the imminent healthcare needs of the aging and chronically ill.”12
References
1U.S. Department of Health & Human Services. (2015, January 26). Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. Retrieved from http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html.
2Shega, J., Hougham, G., Stocking, C., Cox-Hayley, D., & Sachs, G. (2008). Patients dying with dementia: Experience at the end of life and impact on hospice care. Journal of Pain and Symptom Management, 35(5), 499-507.
3Teno, J. M., Gozalo, P. L., Lee, I. C., Kuo, S., Spence, C., Connor, S. R., & Casarett, D. J. (2011). Does hospice improve quality of care for persons dying from dementia? Journal of the American Geriatrics Society, 59(8), 1531-1536.
4Widera, E., & Talebreza, S. (2016). Variability in hospice care at the very end of life. JAMA Internal Medicine, Editorial, pp. 1-2. Published online February 8, 2016.
5Aldrige, M. D., Schlesinger, M., Barry, C. L., Morrison, S., McCorkle, R., Hurzeler, R., & Bradley, E. H. (2014). National hospice survey results: For-profit status, community engagement, and service. JAMA Internal Medicine, 174(4), 500-506.
6Melvin, C. (2008). Hospice referral: What takes us so long? International Journal for Human Caring, 12(3), 24-30.
7Alzheimer’s Association. (2016, March). 2016 Alzheimer’s disease facts and figures. Retrieved from http://www.alz.org/documents_custom/2016-facts-and-figures.pdf
8Mor, V., Joyce, N. R., Cote, D. L., Gidwani, R. A., Ersek, M., Levy, C. R., Faricy-Anderson, K. E., Miller, S. C., Wagner, T. H., Kinosian, B. P., Lorenz, K. A., & Shreve, S. T. (2016). The rise of concurrent care for veterans with advanced cancer at the end of life. Cancer, 122, 782-790.
9Cassel, J. B., Kerr, K. M., Kalman, N. S., & Smith, T. J. (2015). The business case for palliative care: Translating research into program development in the U.S. Journal of Pain and Symptom Management, 50(6), 741-749.
10Morrison, R. S., Penrod, J., Cassel, J. B., Caust-Ellenbogen, M., Litke, A., Spragens, L., & Meier, D. E. (2008). Cost savings associated with US hospital palliative care consultation programs. Archives of Internal Medicine, 168(16), 1783-1790.
11Naylor, D. M., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29, 893-899.
12McLean, A. (2015). Turmoil in primary care: Is there hope for teamwork? Arizona State University, Scholarly Writing.
13Lupu, D. (2010). American Academy of Hospice and Palliative Medicine Workforce Task Force, Estimate of current hospice and palliative medicine physician workforce shortage. Journal of Pain and Symptom Management, 40, 899-911.
14Hospice and Palliative Credentialing Center. Advanced Certified Hospice and Palliative Nurse (ACHPN®). Retrieved from (http://hpcc.advancingexpertcare.org/competence/aprn-achpn/
.
Certification of Terminal Illness 
I was interested to learn about the Medicare Annual Aggregate Cap for hospice agencies. Is this cap allocated to each hospice agency in a capitated pattern per patient? Or is the cap allocated to each agency regardless of patient volume? If it is allocated on a per-patient basis, then it seems as though the Annual Aggregate Cap is already in line with value-based payment models per MACRA. If Medicare were to reduce this cap, as you suggest, would agencies be able to continue to provide high quality care to patients?
LikeLike
Thanks for the comprehensive post, Amy. Working in hospice and palliative care, as you do, I see similar problems. I also see NPs as part of the solution. So many times patients with dementia (PWD) come to hospice after a hospitalization, costing thousands of dollars and producing disorientation for the PWD and the family. To what end? Aggressive care for PWD is not the answer.
When I worked for Evercare, providing care to PWD in nursing homes, I saw the direct benefits to PWD and their families. We NPs would assess patients for acute changes in condition (we called them CICs) and intervene to keep the PWD out of the hospital and help the families navigate the uncertainties that come along with dementia. At times, the families would want us to treat these CICs with something aggressive (to my mind) like IV fluids or IV antibiotics. Even at that, saving hospitalization costs was a win for the insurance company.
To me, scaling this model up and getting all insurers to “buy in” to this type of care makes both fiscal and psychosocial sense. And, how often do you get to do both of those at the same time?
LikeLike
I enjoyed reading your post. It definitely piqued my interest in payments for hospice and how the advanced practice nurse (APN) caring for patients in this setting need to be part of the solution. It is interesting to think about hospice agencies as a for profit business. I have had family members that had hospice care before passing and it does not feel good to me, as a family member, to think that this line of healthcare is profiting off of my dying loved one. I do realize that there are for-profit and not-for-profit hospice agencies and yet I never thought of it this way until reading your post. I will add that my family has used for-profit hospice care. You mentioned that many experts in the field agree that the rest of healthcare should remain capitalistic. This makes me think more about our system of care in general in the United States and the many influencing factors that may affect the quality of healthcare that we receive; whether it is hospice care or any other care. It would seem that a fee for service system leaves all providers vulnerable to increase or add costs directly related to the quantity of services provided per patient in order to receive reimbursements that are reasonable for care delivered.
You mentioned that palliative care services receive inadequate reimbursements. I think that there are many areas in healthcare in which providers receive inadequate reimbursements. I personally believe that this is directly related to why so many primary care provider physicians are leaving the field as well as why many medical students are choosing specialties over primary care. The move to reimbursement being tied to value-based care rather than quantity has the potential to decrease healthcare costs and improve patient quality outcomes. The Physician Quality Reporting Program Strategic Vision that the Centers for Medicare and Medicaid Services (CMS) has implemented seeks to improve the delivery of high quality care for consumers while decreasing the burden (of reporting) on care providers by implementing programs that are guided by input from patients, caregivers, and health professionals and public reporting of data that provides meaningful and transparent performance measures (Centers for Medicare and Medicaid Services, 2015). This may present more opportunities for advanced practice nurse practitioners to play a key role in providing higher quality of care to patients and populations rather than focusing on quantity. Consumers now have the opportunity to have a voice in the quality or lack of quality care received and have this tied directly to reimbursements.
Reference
Centers for Medicare and Medicaid Services. (2015). CMS physician quality reporting programs strategic vision. Retrieved on April 22, 2016 from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Physician_Quality_Reporting_Programs_Strategic_Vision_Document.pdf
LikeLike