Hospice care is one of the fastest growing components of our healthcare delivery system due to the recognition that palliative care is a very appropriate and humane part of healthcare delivery. It also has a significant impact on healthcare system expenditures.
Thirty percent of all Medicare expenditures are attributed to the 5% of beneficiaries who die each year, with a third of that cost occurring in the last month of life, often with little or no impact on the patient’s outcome.1 A recent study published in the Journal of Clinical Oncology found that average Medicare expenditure for a patient in hospice is $6,537, while the Medicare expenditures for a patient who disenrolls from hospice is $30,848.2
Historically, patients and families have not chosen palliative care as an end-of-life option. This may be due to a lack of understanding of the role effective palliative care can have on the patient’s quality of life. Further, our fee-for-service driven healthcare system has historically incentivized care providers to provide as much care as possible in order to generate more revenue.
As an example, on a recent flight I had the pleasure of sitting next to a very nice physician’s assistant traveling from Fort Worth, Texas, to Minneapolis to unwind a healthcare situation developing with her parents. Her father was 89 years old and his cardiologist had convinced her mom and dad to go forward with a heart transplant to help alleviate is heart failure. Her father had chronic obstructive pulmonary disease (COPD) and colon cancer. The PA knew a heart transplant was an unreasonable course of treatment and was determined to convince her parents that palliative care was the much better option for her father.
The Institute for Healthcare Improvement’s Conversation Project is a demonstration of the healthcare industry’s push toward more effective and appropriate ways of handling end-of-life issues.3 In fact, a 2012 report to Congress from the Medicare Payment Advisory Commission (MedPAC) recommended that Medicare increase the payment rate for hospice care as an incentive to enroll more patients into hospice programs.4
We have illustrated several times in this series how the Affordable Care Act (ACA) transformed the financing of the healthcare system and does so, in large part, through the alignment of incentives for improving patient outcomes. End-of-life and palliative care is another example of this incentive alignment. There was much discussion during the early development of the ACA about “death panels.” In the final version, the ACA did not specifically address payment reform for end-of-life care, but it did raise the awareness that the healthcare system does need to handle this issue in a more proactive way.
Hospice Economics
Hospice agencies have an interesting economic model. When a patient is enrolled in hospice, the hospice fee (typically a per-diem payment based on the setting of the care and patient diagnosis) is designed to cover all hospice-related care for the patient. If the patient’s cost for delivering services in the hospice plan of care exceeds the revenue generated from the hospice payment, the hospice agency loses money. The clinical, emotional and economic incentive for home hospice is to help the patient transition to their next care setting peacefully at home (we often refer to this as “getting onto the escalator”). Consequently, ambulance trips to high-cost care settings such an emergency department, or an in-patient hospital stay for a hospice-related episode of care, is not in the best interests of the hospice agency, the patient or the family.
As many of us in EMS know, there are times (typically at or near the end of life) that the patient’s family wants everything done to save the patient’s life, or they are simply scared in the final moments and activate the 9-1-1 system. Often, that means much confusion on the scene of the call and all too often results in an expensive ambulance trip and an even more expensive hospital stay. The patient or patient’s family may then also voluntarily dis-enroll the patient from hospice once in the hospital. This means that the hospice agency has expended dollars for the patient’s care and then loses the per-diem revenue for the rest of the patient’s potential hospice enrollment. This is not an effective economic model for the hospice agency.
Further, if the patient and/or the patient’s family is noncompliant with the hospice plan of care by insisting everything be clinically done for the patient or by routinely calling 9-1-1, the hospice agency may have an incentive to disenroll the patient from hospice status. If the patient disenrolls, the cost of caring for that patient reverts to traditional payer models, typically Medicare. Sometimes, once the high-cost care episode is over, the hospice agency may wish to re-enroll the patient to hospice service. CMS discourages hospice agencies from churning patients in and out of hospice status.
The EMS/MIH Solution
To help avoid these potential pitfalls, hospice agencies are beginning to look to EMS for a mobile integrated healthcare (MIH) strategy to help safely transition the patient from home hospice to another setting (either in-patient hospice status or beyond) and are willing to pay for those services. In the case of my agency, MedStar in Fort Worth, VITAS Innovative Hospice is funding a program to help patients successfully make this transition.
VITAS assesses patients and families they enroll into hospice and uses a special tool to determine the potential risk for a voluntary disenrollment. Green means low risk, yellow is moderate risk and red is high risk for voluntary disenrollment or revocation. Patients categorized as red or yellow are referred for enrollment into the VITAS/MedStar hospice revocation avoidance program.
Once identified, a MedStar mobile healthcare practitioner (MHP), all of whom have been specially trained by VITAS to help with end-of-life care issues, and a VITAS hospice nurse conduct a joint home visit with the patient and patient’s family. The program is explained to the family and patient and they are reminded that the primary contact for any hospice-related medical issues is the VITAS hospice nurse. They are provided a 10-digit number to access MedStar’s 24-hour call center if for some reason they are unable to reach the hospice nurse right away. This provides an additional level of reassurance for the patient and family. Once enrolled, important documents such as the patient’s do-not-resuscitate (DNR) orders are scanned and entered into MedStar’s electronic medical record system for ease of access in the likely event they cannot be found at the emergency scene.
MedStar also registers the patient into our computer-aided dispatch (CAD) system with an address flag that contains the information that the patient at this address is enrolled in the hospice revocation avoidance program and the contact phone number for the on-call VITAS hospice nurse. If the family calls 9-1-1, the call goes through the usual emergency medical dispatch (EMD) process, with an additional question added to the end of the case entry and key question process:
“With the information you have provided about the patient’s complaints, we would normally send an ambulance to your residence. Would you like for us to start one that way, or would you prefer we send just [the specially trained paramedic] to evaluate and help you with your concerns/questions?”
If the caller opts for only the MHP to respond, we do that, and call the hospice nurse to let them know we are on the way and to please join us. If a regular EMS system response is requested, we send it, with an MHP added to the response along with notification to the hospice nurse that we are responding.
Once on scene, if the response is for something not within the hospice plan of care, such as a fall or other injury, the patient is treated and transported as with any other patient since this is not part of the care plan, and we cancel the hospice nurse to the scene. However, if the medical issue is within the hospice plan of care, the patient and family are reassured and provided with any needed clinical or emotional support while the hospice nurse is on the way to the residence to assume care of the patient and family. Through a special medical control arrangement between the MedStar medical director and the hospice agency medical director, our MHPs are authorized to access the patient’s “comfort pack,” which often includes medications to alleviate pain and suffering, and administer that medication to the patient.
In some cases, the on-scene MHP and the hospice nurse may decide it is in the best interest of the patient and the family for the patient to be transferred from an out-patient hospice setting to an in-patient hospice setting. In these cases, the patient may be transported from the home setting to an in-patient hospice setting, preventing a disenrollment while providing additional support for the patient and family.
Fee Structure
There are a number of economic models that can be used by an EMS-based MIH solution for hospice patients.
• Fee for enrollment: The hospice agency pays a fee to have the patient enrolled in the program.
• Outcome-based payment: The EMS agency is paid a fee when the patient successfully gets onto the escalator at home without a hospice revocation.
• Capitated payment: The hospice agency pays a monthly fee for each patient enrolled in the program.
Summary
The healthcare system is moving quickly to more effectively dealing with end-of-life care for patients. Hospice patients have historically been a unique challenge for EMS agencies. Scenes are often chaotic and difficult to manage, not necessarily from a clinical perspective, but from an emotional and legal perspective. Working collaboratively with hospice agencies to effectively navigate their patients through the last moments of the end-of-life process improves the patient’s and the family’s experience of care, improves patient outcome (in a nontraditional way—death in these cases is the better outcome) and reduces costs to the healthcare system. This is probably why the IHI has adopted the Conversation Project and why EMS-based MIH should adopt new ways of helping this growing population of patients.
REFERENCES
1. Barnato A, McClellan M, Kagay C, et al. Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Services Research. 2004;39(2):363–376.
2. Carlson M, Herrin J, Du Q, et al. Impact of hospice disenrollment on healthcare use and Medicare expenditures for patients with cancer. Journal of Clinical Oncology. 2010;28(28):4371–4375.
3. IHI (n.d.) The Conversation Project. Retrieved on June 11, 2014, from www.ihi.org/Engage/Initiatives/ConversationProject/Pages/default.aspx.
4. MedPAC. (March 2012) Hospice Services. Retrieved on June 11, 2014, from www.medpac.gov/chapters/Mar12_Ch11.pdf.
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