Two recent announcements by the Centers for Medicare and Medicaid Services (CMS) demonstrate a clear commitment to improving the quality of care for older adults with serious illnesses. Together with the introduction of a bipartisan bill to better train our nation’s health care workforce, these announcements suggest that the tide is turning in the effort to provide high-quality, patient-centered care to medically complex and seriously ill patients.
The first CMS announcement, released on July 8, is a proposed rule to establish separate payment for advance care planning (ACP) services.
“For Medicare beneficiaries who choose to pursue it, advance care planning is a service that includes early conversations between patients and their practitioners, both before an illness progresses and during the course of treatment, to decide on the type of care that is right for them,” and as CMS correctly notes, ACP services “would better enable seniors and other Medicare beneficiaries to make important decisions that give them control over the type of care they receive and when they receive it.”
Indeed, patient-centered, goal-directed treatment is the cornerstone of high-quality, high-value care, and yet the time and skills required to elicit and discuss patients’ personal values and goals had not previously been reimbursed under the Medicare fee-for-service program. While the proposed rule will not take effect until January 2016, it is one important step toward creating a system that will maximize personal autonomy and responsibility, and also incentivize high quality care, in place of the current model that rewards doing more regardless of the individual patient’s priorities. With little public backlash so far, there is reason for optimism that the proposed rule will become final.
The Medicare Care Choices Model
In addition, CMS announced the hospices selected to be a part of the Medicare Care Choices Model, a program that will expand access to home-based palliative care services to as many as 150,000 eligible Medicare beneficiaries. Through this program, the selected hospices are able to enroll patients in need of supportive services, who qualify for the Medicare hospice benefit but who desire and still may benefit from concurrent “curative” (i.e., disease-focused) treatment services.
Since 1982, the Medicare hospice benefit has provided comprehensive, interdisciplinary (medicine, nursing, social work, and chaplaincy) team-based palliative care, most commonly in the home, for dying patients with an identifiably short prognosis of less than six months. Hospice care is only available, however, when patients and their families decide to forgo insurance coverage for curative or disease-directed therapies in order to focus solely on maximizing comfort and quality of life. This “either-or decision” forces patients to give up all disease-directed treatments, some of which may be palliative in nature, in order to access hospice care and is a statutory requirement often described by hospice leaders as “the terrible choice.”
Palliative care, in contrast, is interdisciplinary care that focuses on improving quality of life for persons living with any serious illness and their families, regardless of their prognosis. By treating pain, other symptoms, and psychological and spiritual distress; using advanced communication skills to establish goals of care and help match treatments to those individualized goals; and providing sophisticated care coordination, palliative care provides an added layer of support to patients, their loved ones, and treating clinicians. Ideally, palliative care is provided from the time of diagnosis and concordantly with all other disease-directed or curative treatments.
The vast majority of large hospitals in the U.S. now have palliative care services available for inpatients. While palliative care needs clearly do not cease upon discharge from the hospital, access to community and home-based palliative care services has been extremely limited, largely due to inadequate methods for reimbursement outside of the hospice benefit.
The Medicare Care Choices Model begins to address that critical gap in care. Hospices participating in the model will “provide services that are currently available under the Medicare hospice benefit for routine home care and respite levels of care, but cannot be separately billed under Medicare Parts A, B, and D. Services will be available around the clock, 365 calendar days per year, and CMS will pay a per beneficiary per month fee ranging from $200 to $400 to participating hospices when delivering these services under the model.”
In contrast, CMS reimburses approximately $160 per beneficiary per day for these services under the traditional hospice benefit. In research settings, non-hospice outpatient and home-based palliative care programs have demonstrated improved symptom management and patient and family satisfaction scores, as well as significant reductions in hospital admissions, emergency department visits, intensive care unit days, and physician office visits. We hypothesize that the Medicare Care Choices Model may result in similar outcomes.
Essential Pillars Of Quality of Care
To achieve those outcomes, we must focus on three essential pillars of quality of care for medically complex or seriously ill persons:
- Understanding what matters most to patients in the context of the illness and its likely future course (now supported by Medicare’s proposed rule reimbursing providers for these complex and often ongoing advance care planning conversations);
- Ensuring that once these priorities (for example, wanting to remain at home and avoid life in a nursing home) are known, that our delivery and payment system can honor these wishes (supported by the Medicare Care Choices Model, allowing people to receive home-based palliative care at the same time as disease-directed treatment); and
- Training all of the nation’s health professionals to deliver quality primary palliative care (i.e., pain and symptom management, skillful communication over the full course of illness, and coordinated care across settings and over time) during what is often a decade or more of chronic progressive illness.
Supporting patient autonomy and goal-directed care through payment for advance care planning and expanding home-based palliative care services through the Medicare Care Choices Model are critical steps toward achieving two of the three pillars of high-quality care for older adults with serious illness. The missing link is clinician training.
It is widely known and well-documented that our nation’s undergraduate and graduate health professional training programs have failed to prepare the workforce for an aging and chronically ill patient population. No matter how we pay for care, if clinicians do not know how to prevent and treat pain and symptom crises, patients and their loved ones will continue to be forced to call 911 for help. No matter how we pay for care, if doctors and other clinicians are not trained to initiate conversations, elicit what matters most to their patients, and work with them to develop care plans that achieve the patient’s top priorities, then the default and impersonalized pattern of having more scans, more interventions, and costly futile (and often harmful) medical treatment will continue.
The palliative care needs of the aging U.S. population are vast, and the specialist palliative care workforce pipeline is inadequate. Training in the fundamental principles and practices of palliative care (e.g., symptom management, communication skills) is needed across all medical, nursing, and allied professionals’ training programs so that every clinician has the basic knowledge and skills necessary to provide adequate care for the sickest and most complex patients.
Expansion of specialist training programs and support for academic palliative care programs in education and research are also vital. The good news is that the federal government may soon have a vehicle to address this crucial third pillar. The Palliative Care and Hospice Education and Training Act (PCHETA/HR 3119) was introduced on July 21 by the bipartisan team of Congressional Representatives Tom Reid and Eliot Engel. The companion Senate bill is expected soon, and advocates from the Patient Quality of Life Coalition spent the day on the Hill on July 21 seeking co-sponsorship.
PCHETA/HR 3119 calls for investment in basic training of the health care workforce, as well as support for public awareness and for attention from the National Institutes of Health to build the evidence base for improving quality of life. The 2014 Institute of Medicine Report, Dying in America, called for exactly this kind of investment in preparing our workforce for the needs of our society.
The tide is turning.