Jim’s Notebook: The Potential of Concurrent Hospice Care

Photo credit: DarkoStojanovic

Big news this week: CMS announced a six-month national moratorium on hospice enrollment in Medicare, in a move aimed at curbing waste, fraud and abuse. I’ll share more thoughts on this move in upcoming posts here, and in the meantime, you can read our Hospice News coverage.

Now, on to our regularly scheduled programming:

I was honored to be asked to present at a board meeting of a nonprofit hospice last week. It was a good time. I talked a lot about trends that were happening now in the hospice space and about the direction I think the hospice community is heading.

I would like to share some of my thoughts about one of the topics I spoke about — the potential for some type of concurrent curative and hospice care.

But first, if you haven’t seen it, check out my last post on the urgent needs of hospice family caregivers.

Concurrent care in hospice settings could expand options for patients and families while easing concerns about losing access to additional treatment.

I believe that fears surrounding hospice enrollment — particularly the worry that patients may be unable to receive other needed services — could diminish if concurrent care were more widely available.

It’s also important to note that while distinctions between curative care and palliation may appear straightforward in policy, the reality is often far more complex. Consider the example of radiation treatments that can be used for both curative and palliative purposes. These treatments are often discontinued when a patient enters hospice, even though the patient may still be able to benefit from them in some ways.

The U.S. Centers for Medicare & Medicaid Services (CMS) has also been thinking about this. In recent years, the agency has issued several requests for information regarding the provision of what it calls high-acuity palliative services, like radiation, chemotherapy, dialysis and blood transfusions.

One of the most closely watched examples of how concurrent care could work is the Medicare Care Choices Model (MCCM), a demonstration project launched by the Center for Medicare & Medicaid Innovation between 2016 and 2021 to evaluate the effects of allowing concurrent hospice care.

According to a 2022 report, the model included roughly 4,500 Medicare fee-for-service beneficiaries who had died by March 2021. Participants had a six-month terminal prognosis and diagnoses including cancer, congestive heart failure, chronic obstructive pulmonary disease or HIV/AIDS. Patients were referred to one of 141 participating hospices nationwide.

The model had limitations, including relatively low participation. At the time, nearly 5,000 hospices operated nationwide, while approximately 1.7 million people elected hospice care annually. By comparison, the MCCM enrolled only 4,500 beneficiaries across 141 hospices.

Researchers noted that while the results were statistically significant, questions remain about how broadly the findings can be applied. As with many demonstration projects, the possibility exists that unobserved differences among participants or providers may have influenced the outcomes.

Despite these lingering questions, we can’t throw the baby out with the bathwater.

The MCCM ultimately found that concurrent palliative and curative services reduced total costs of care by 14% compared with a control group — approximately $7,500 in savings per patient.

The model also demonstrated reductions in emergency room visits and ICU utilization while increasing the number of days patients were able to remain at home, outcomes that contributed to the overall cost savings.

Policymakers, in addition to CMS, are also beginning to ask questions about the potential for concurrent care.

During a visit to Capitol Hill a couple of years ago, I met with some of the lawmakers from both sides of the aisle, and some members of Congress brought up the potential for concurrent care. It honestly kind of surprised me that they knew what it was, but concurrent care was on their radar.

I think that examining concurrent care as a strategy could improve utilization, reduce overall health care spending and support aging in place — outcomes viewed as both patient-centered and cost-effective by most stakeholders.

What do you think about the prospect of concurrent care? I would love to hear more about the individual provider perspective on this. Please drop a comment or send me a message.

Notable quote

I came across this remarkable quote about bereavement from musician and author Nick Cave, who has frequently spoken publicly about grief since the loss of his parents and two of his sons.

“Grievers point the way towards tending a world many of us feel is in urgent need of reparation. These apprentices of loss are the holy ones who, for an excruciating time, live in acute and shocking proximity to the essence of things. They stand at the point of revelation, deep in grief, blindly gesturing towards some unbidden thing, unaware that the unbidden thing is grief’s own outrageous beauty awaiting them. They have shown me the way forward, and I love them for that.”

I thought there was a lot of beauty and truth in Cave’s words, which he wrote on his Red Hand Files website.