Yesterday, CMS announced a concurrent hospice demonstration that will begin this Summer in the Medicare program. 30 hospices will be allowed to begin the 3 year pilot, and must apply by summer 2014 to do so. The so-called Medicare Care Choices Model will allow hospices to provide care to Medicare beneficiaries without their having to “unelect” curative care first (they must do so now under the hospice benefit).

I haven’t been able to invest lots of time investigating this yet, but I am unsure if this is the Hospice payment demonstration enabled by Section 3140 of the ACA.  This FAQ sheet says it is enabled under Section 1115a of the Social Security Act (though it is possible that Sec 3140 of ACA amended 1115a; don’t have time to dig it out). And I think the ACA demonstration was a far broader demonstration for new payment models for hospice more comprehensively, and talked of 15 instead of 30 hospices.

The demonstration will allow hospice providers to receive $400/month to interact with and monitor patients. Other providers will continue to bill Parts A (hospital), B (doc) and D (pharma). I must say that my first thought was $400/month is not very much, so I actually don’t get how this will be the case:

Hospices that apply and are selected to participate in Medicare Care Choices Model will provide services available under the Medicare hospice benefit for routine home care and inpatient respite levels of care that cannot be separately billed under Medicare Parts A, B, and D. These services must be available 24/7, 365 calendar days per year. CMS will pay a $400 per beneficiary per month fee to the Medicare Care Choices Model participating hospices for these services.

As $400/month is less than 3 days of the general hospice per diem, I believe this is essentially allowing patients to have a comprehensive goals of care/family discussion for seriously ill patients who are not ready to elect hospice as their primary provider of care. If they later do choose hospice, will they then still have to unelect curative services as with current hospice policy, and the hospice would then bill Medicare for the normal hospice benefit? Or does the language of “not otherwise available in Parts A, B and D mean that hospices get $400/month to get involved, and then simply bill the hospice benefit concurrently for actual care provided using the hospice per diem? It must be the latter, but I think some further clarity is needed.

I see this amount of money ($400/month) as basically a test of whether exposure to early hospice care can yield the positive outcomes found by Temel et al. 2010 with stage 4 lung cancer. However, the snippet above sounds like hospices are on the hook for all hospice care 24/7, so it must mean that they can bill hospice concurrently above and beyond the $400/month. The patient population is restricted to those with advanced cancer, COPD, CHF, and HIV/AIDS. They have basically excluded dementia, debility and failure to thrive, the diagnoses associated with longer lengths of hospice use, which actually makes sense to me.

I am a big fan of concurrent hospice/palliative care and think it is the direction we should move. However, I don’t fully understand the economics/rules of what care is actually going to be provided at this point and need to dig further.

update: AAHPM says this is the demo authorized by sec 3140 of ACA.

cross posted at freeforall