August 17, 2017

The Medicare Choices Care Model: Either/Or Becomes This and That

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“I see it all perfectly; there are two possible situations – one can either do this or that.”

You would be forgiven if you thought this quote was about a Medicare policy concerning whether a patient could either continue with curative treatment or enter into hospice care. You would be forgiven, but you would still be wrong – and wrong twice.

First, the quote is not from Medicare, but from the great 19th-century Danish thinker Soren Kierkegaard’s appropriately titled book, “Either/Or.”

Second and most importantly, under the new Medicare Choices Care Model (MCCM) trial program, terminally ill Medicare patients will no longer have to choose either curative therapy or hospice care. In 2014, the Centers for Medicare & Medicaid Services (CMS) determined that only 44 percent of terminal Medicare beneficiaries used their hospice benefit during the final stages of their illnesses, and that those who used it did so for only a very short time. Medicare developed the MCCM to remedy this.

The goal of the MCCM program is to increase the number of terminally ill patients entering into hospice care by waiving the requirement that patients must forgo treatments such as chemotherapy. A Phase 1 pilot program of the MCCM was launched in January 2016 and involved 30 hospices in multiple states.

Due to the robust interest in the Phase 1 pilot, a second phase is planned to debut on Jan. 1, 2018, increasing the number of hospice providers to 140. Medicare anticipates that the 2018 Phase 2 rollout will enroll 150,000 terminally ill patients limited to four diagnostic groups: HIV/AIDS, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and cancer. The MCCM trial program is planned to run until Dec. 31, 2020.

The intent of this MCCM trial program is to determine if expanded benefits involving both continuing curative treatment and hospice care will increase earlier enrollment of Medicare patients in hospice – and to see if this will improve care, enhance satisfaction, and reduce costs.

Medical thought leaders have long been persuaded that allowing concomitant curative therapies and hospice care will improve quality of life for patients and caregivers, but will not increase costs. The expectation is that by offering the choice of hospice care without eliminating continuing curative therapies, enrollment in hospice will increase as more Medicare beneficiaries avail themselves of palliative care for themselves and of respite care for their families.

The very positive response to Phase 1 of the MCCM highlights the very difficult choices patients and their families have had to make in the past about whether to either continue with curative treatment or forsake this treatment for palliation and comfort. In addition to the four diagnostic categories to be eligible for the MCCM, patients must not have elected the Medicare or Medicaid hospice benefit in the previous 30 days.

The nuts and bolts of MCCM will work something like this for patients and their doctors – under MCCM, the notice of election of hospice will not turn off Part A, B, or D coverage, so services to treat the terminal condition can continue and be billed as a separate claim. These Part A, B, and D services for which providers can continue to bill Medicare include the following:

  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Drugs for management of pain
  • Drugs for management of symptoms of the terminal illness
  • Medical equipment and supplies
  • Physical services
  • Short-term inpatient care for pain and symptom management

Payment to hospice differs from traditional payment. Hospices participating in MCCM will not receive the Medicare hospice benefit per diem rate. Instead the MCCM will pay hospices a flat fee of $400 monthly for 15 or more days of services, per month. If services are provided for fewer than 15 days per month, the monthly payment decreases to $200. Among the MCCM hospice services covered under the per-month payment, and not subject to a copay, are the following:

  • Counseling services
  • Psycho-social assessment
  • Nursing services
  • Medical social services
  • Hospice aide and homemakers services
  • In-home respite care

Medicare’s expectation is that patients will enter the MCCM through both physician and hospice referral. CMS published a recent MLN Matters in May 2017 detailing the MCCM, which can be accessed online at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10094.pdf.

The MCCM is an innovative CMS program designed to serve Medicare’s most vulnerable population – the terminally ill. It is Medicare’s intent that those patients whose clinical trajectory is headed toward death will no longer have to choose between either the hope of curative therapy and or the comfort of hospice care.

Under the MCCM, “either or” really will become “this and that.”

Michael A. Salvatore, MD, FACP, CHCQM

Dr. Michael Salvatore was a pulmonary medicine/critical care physician for 35 years. Since 2012 he has been the physician advisor and medical director of the palliative care team at Beebe Healthcare in Delaware. After earning his MD at the University of Arizona, he trained in internal medicine and PULM/CCM at Duke University. Dr. Salvatore is a member of the RACmonitor editorial board.

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