Dying in America Improving Quality and Honoring Individual Preferences Near the End of Life (2015) / Chapter Skim
Currently Skimming:
Appendix D: Financing Care at the End of Life and the Implications of Potential Reforms
Appendix D: Financing Care at the End of Life and the Implications of Potential Reforms
Pages 455-486
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 455... ...
Stevenson, Ph.D.2 As with other health care services, the manner in which end-of-life care is financed in the United States has a substantial impact on the care that is delivered. In the following paper, we examine the implications of financing and payment methods for end-of-life care for utilization, quality, and expenditures of individuals with advanced illness.
|
From page 456... ...
While the inpatient share of Medicare expenditures for decedents aged 65 and older in a given year has dropped dramatically over the past 30 years, inpatient care still accounted for half of all Medicare spending -- 50.2 percent -- among elderly decedents in 2006 (see Table D-1) (Riley and Lubitz, 2010)
|
From page 457... ...
. Focusing only on Medicare expenditures provides a narrow picture of health care spending at the end of life, particularly for nursing home residents, approximately two-thirds of whom are dually eligible for Medicare and Medicaid and receive Medicaid-financed long-term services and supports.
|
From page 458... ...
; physician practices; and even the level of an individual physician after controlling for demographic characteristics, insurance plan factors, and market-level characteristics. Importantly, the variation in total Medicare spending was driven largely by the utilization of post-acute services, including SNF services, home health care, hospice, inpatient rehabilitation, and long-term acute care; if there were no variation in post-acute care expenditures, then variation in total Medicare spending would decrease by 73 percent (IOM, 2013)
|
From page 459... ...
With some exceptions, such as the Medicare hospice benefit (described later in this appendix) , insurance coverage for individuals with advanced and terminal illnesses reflects coverage that is available to enrollees more generally.
|
From page 460... ...
KEY LIMITATIONS OF CURRENT FINANCING APPROACHES The payment approaches used most commonly by Medicare, Medicaid, and commercial payers have a number of limitations that can contribute to suboptimal care at the end of life. Given its prominence in financing endof-life care in the United States, we focus primarily on the role of Medicare, including the Medicare hospice benefit.
|
From page 461... ...
payment system that is the foundation of reimbursement for services used by the nearly three-quarters of Medicare beneficiaries enrolled in the traditional Medicare program (IOM, 1997)
|
From page 462... ...
. In particular, nursing homes and beneficiaries face financial disincentives to enrollment in Medicare hospice instead of Medicare-financed SNF care when both are an option.
|
From page 463... ...
. Together these eligibility requirements can serve to delay or prevent enrollment in the Medicare hospice benefit for some beneficiaries, effectively denying them access to palliative care services.
|
From page 464... ...
Outside of the hospice benefit and these narrow provisions for physician consultation, there is no direct financing stream for palliative care services under the Medicare program (CAPC, 2009)
|
From page 465... ...
. Researchers have argued that the current structure of the Medicare hospice benefit may be a particularly poor fit in the nursing home setting.
|
From page 466... ...
This policy creates a strong financial incentive for plans to promote hospice enrollment among their more expensive terminally ill enrollees, while also diminishing -- at least somewhat -- incentives to develop integrated, high-quality palliative care networks for people with advanced illness. MedPAC voted in January 2014 to end this hospice carve-out policy, recommending that MA plans begin to cover hospice services for the first time.
|
From page 467... ...
Other Integrated Financing Models In addition to the MA program, other approaches to integrated financing and delivery have relevance for Medicare beneficiaries with advanced illness and offer potential advantages over Medicare's traditional FFS program. For instance, the Program of All-Inclusive Care for the Elderly (PACE)
|
From page 468... ...
Yet the almost exclusive focus on the latter types of measures has the potential to impede appropriate end-of-life care for residents, because some measures that may address natural symptoms experienced in the dying process (e.g., functional decline, weight loss, dehydration) could be interpreted as implying poor-quality nursing home care (Huskamp et al., 2012)
|
From page 469... ...
Some of these reforms are being implemented as Medicare demonstration programs authorized under the ACA; others are being considered or adopted more broadly in the Medicare program, the commercial market, and/or state Medicaid programs. Bundling of Payments to Providers There is now broad national interest on the part of payers, including private insurers, Medicare, and Medicaid, in identifying alternatives to FFS payment (Kirwan and Iselin, 2009; Schroeder and Frist, 2013)
|
From page 470... ...
. More important, relative to an FFS system, paying providers a fixed rate that covers a bundle of services can create incentives for them to stint on care or attempt to select patients who have lower-thanaverage expected costs, creating potential access problems for relatively sicker patients -- something that is seen currently in the Medicare hospice benefit (Aldridge et al., 2012)
|
From page 471... ...
the Medicare Bundled Payments for Care Improvement Initiative (BPCII)
|
From page 472... ...
. More specifically, previous studies have shown that early integration of palliative care for individuals with advanced illness has the potential to reduce health care costs overall (Morrison et al., 2008)
|
From page 473... ...
. Early results from the first year of the Pioneer ACO model suggest that Medicare spending per beneficiary for individuals enrolled in these organizations grew at a slower rate overall than spending for beneficiaries enrolled in the FFS program in their area, although results differed across Pioneer ACOs (L&M Policy Research, 2014)
|
From page 474... ...
Another new initiative that is related conceptually to the idea of better integrating care individuals receive through the Medicare program involves integrating Medicare and Medicaid financing for individuals who are dually eligible for both programs. Also created by the ACA, the State Integrated Care and Financial Alignment Demonstrations for Dual Eligible Beneficiaries allow states to use one of two models to coordinate services for dually eligible individuals, something that has been challenging historically.
|
From page 475... ...
. Concurrent Care Models The ACA calls on the Secretary of Health and Human Services to create a Medicare Hospice Concurrent Care demonstration program under which
|
From page 476... ...
and (2) by requiring a prognosis of 12 or fewer months for hospice eligibility (as opposed to the 6-month prognosis requirement for the Medicare hospice benefit, which would still apply under the Medicare Concurrent Care demonstration)
|
From page 477... ...
There are no data on the relationship between use of the Medicare hospice benefit and Medicare spending for longer stays because of smaller sample sizes in the upper tail of the distribution of stay duration. As a result, the extent to which demonstration sites might be able to meet the budget neutrality requirement could depend on who enrolls in the program and the duration of stays that result from the implementation of concurrent care.
|
From page 478... ...
Existing concurrent care models would not, however, address any barriers to high-quality palliative care created by the 6-month prognosis requirement. ACA-AUTHORIZED CHANGES TO MEDICARE HOSPICE REIMBURSEMENT The ACA calls on the Secretary of Health and Human Services to implement revisions to the payment methodology for hospice services no earlier than October 1, 2013.
|
From page 479... ...
• Given the special concerns inherent in the financing of care for nursing home residents at the end of life, payment models that bundle acute, post-acute, and end-of-life care should be explored, again using mixed payment methods. Some package of hospice and palliative care services should be made available to nursing home residents while they are on the Medicare SNF post-acute care benefit.
|
From page 480... ...
In par ticular, the Nursing Home Compare tool could implement such improvements in the near term to ensure that its focus is not ex clusively on restoration and maintenance of functioning. • Changes in Medicare hospice benefit payment authorized by the ACA and implemented by the Secretary of Health and Human Services should attempt to match expected costs and payments for different types of hospice stays while ensuring access to high quality end-of-life care for all beneficiaries with advanced illness, including those with high-cost palliative care needs.
|
From page 481... ...
2013a. Bundled Payments for Care Improvement (BPCI)
|
From page 482... ...
2005. Dying in America -- an examination of policies that deter adequate end-of-life care in nursing homes.
|
From page 483... ...
2014. Effect of pioneer ACOs on Medicare spending in the first year.
|
From page 484... ...
2004. Hospice care in nursing homes: Is site of care associated with visit volume?
|
From page 485... ...
2013. The effect of pay-for-performance in nursing homes: Evidence from state Medicaid programs.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.