I recently interviewed Dr. Kurt Merkelz, the chief medical officer of Compassus, for Hospice News. We had a great conversation focused largely on end-of-life planning and patients coming onto hospice too late. However, he also had things to say about Medicare Hospice Benefit reform, with ideas about a new potential payment model.
Not all of that was able to fit into the Hospice News piece, so I wanted to share more of the interview here.
I’d also love to hear from you in the comments. Do you think the hospice benefit needs reform?
Do healthcare providers upstream of hospice typically initiate these kinds of conversations?
That’s highly variable. They do when the pathway is clearly evident, when the prognostication is clear that the patient is actively coming towards the end – that last two weeks of life. And that’s why the median length of stay is around 17 to 18 days.
People aren’t having those conversations because it’s difficult to prognosticate, and there is a worry that if they get it wrong, then there’s going to be penalties, or that they can’t certify them. There’s myriad reasons why. I think the biggest one is a prognostication deficit.
What do you mean by that – a prognostication deficit?
Bodies are complex. Alzheimer’s is the perfect example in which [the U.S. Centers for Medicare and Medicaid Services (CMS)] is struggling. Generally, with the advanced-stage, frail Alzheimer’s patient, there’s usually an enticing event, such as a fall with or without a fracture or some type of injury, urinary tract infection or pneumonia. Now the patient stops talking, stops eating, stops walking, stops attending to care, becomes more resistant, more cognitive decline, whatever it may be, and so that you appropriately refer to hospice.
The problem was that inciting the event that dropped them down may be a new baseline that they work from, or they may continue on that trajectory. Who knows? Once the infection resolves, the injury resolves, the patient may be at a new baseline.
Then we get to six to nine months later. There were no questions that they were appropriate. But now CMS is wanting to say, “This patient should never have been admitted. They say the prognosis was not supported.” Well, it clearly was. The patient stabilized, but they’re no better. They didn’t regain any function. They didn’t restore. They didn’t cure. They’re still advanced stage, but now it has become problematic.
So, no, I don’t think that they’re having these discussions enough for a prognostic reason. And the second is because the system lacks an understanding of what to offer. So that comes back to goal-concordant care. They lack an understanding of how to reduce caregiver burden, how to avoid hospitalization.
There are specific steps that can be done with med management, with safety mitigation, but there’s no standardized approach, and I think that’s what is really lacking. The physician doesn’t refer those patients earlier because they’re not sure what to refer them to.
Do you think that there’s a discomfort in the healthcare community about discussing hospice, death and dying?
Absolutely, and hospice itself has been part of the reason. It sets up a very known, linear path of what’s going to happen to the patient if you stop doing aggressive treatments. So a lot of it comes back to that pathway and that barrier. I think that exists.
The benefit itself, the way it’s currently structured, it hasn’t been modified in such an incredible long period of time. Chronic kidney disease is a wonderful example. There’s an entire subset of patients that have no access to hospice outside of just stopping their hemodialysis. Even patients who are declining, there’s not a good way of allowing these patients to get supportive care and supportive palliative hemodialysis while their condition declines.
There’s also this six-month trajectory, which is based on a cancer diagnosis and doesn’t apply to many of the chronic disease states nowadays. So the payment system where we get patients up front who may need more aggressive care should get a much higher rate in reimbursement, and then we should look at more stagnated reimbursement after three months, at six months, at nine months, maybe at a year, to offset the cost that comes with this type of condition, or these type of chronic conditions.
It’s time for Medicare hospice reform, and that just hasn’t taken place yet. It needs to. So we’re all trying to figure out how to work within the confines of an outdated system. As diseases, medications and treatments have progressed, the structure of the benefit hasn’t.