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When the Medicare Hospice Benefit (MHB) was written into law in 1982, beneficiaries had to have a prognosis of 6 months or less (if the illness ran its normal course) and the person had to agree to give up curative care. These restrictions were mostly put into place for cost reasons and have remained in place to this day. Even now, Medicare and dually eligible beneficiaries are required to forego curative care in order to receive services under the MHB.
Perhaps as a result of having to make such a difficult choice, fewer than half of eligible Medicare beneficiaries use hospice and most only for a short period of time, even though the hospice benefit is for 6 months and can be renewed indefinitely if the person is still certified as terminal.
The Medicare Care Choices Model (MCCM) was therefore designed to:
- Increase access to supportive care services provided by hospice;
- Improve quality of life and patient/family satisfaction;
- Inform new payment systems for the Medicare and Medicaid programs.
MCCM is a national test from CMS’ CMMI that allows Medicare beneficiaries to receive hospice-like support services from set hospice providers while also receiving services provided by their curative-care providers. The goal of the model is to see if providing these additional supportive services can improve quality, increase satisfaction, and reduce Medicare expenditures.
MCCM is available to beneficiaries who are eligible for the MHB and dually eligible beneficiaries who are enrolled in traditional Medicare and eligible for the MHB – in other words, they must still meet the “six-month” prognosis rule as well as other eligibility criteria. Furthermore, participation is limited to beneficiaries with advanced cancers, chronic obstructive pulmonary disease (COPD), congestive heart failure and HIV/AIDS. If the model is successful, we expect concurrent services will become available to all those with terminal illnesses who meet the other MHB eligibility criteria.
It was expected that as many as 150,000 eligible Medicare beneficiaries would participate in this demonstration, but CMS just announced that as of December 2017, only 1,325 beneficiaries had been enrolled. While CMS relaxed the eligibility criteria during the first phase of MCCM, low enrollment reflects that there are still entry barriers to the model. To date, 10% of beneficiaries approached about the model elected hospice immediately, and nearly 80 percent of those who enrolled in MCCM elected hospice when they left the model.
Services and Payment
Hospices participating in MCCM must provide access to services for patients and their families around the clock. This includes care coordination, case management, symptom management, and other support for beneficiaries and families. Participating hospices receive a per beneficiary per month fee of $400 for a full month, or $200 for half a month of care.
Hospices to date report losing money on the model. However, they see it as an important investment in innovation and are hopeful that CMS’ data will support expanding the model, while also showing that payment for these services must be explored further.
Due to robust interest, CMS expanded the model from an original 30 hospices to over 140 and extended the duration of the model from 3 to 5 years. Currently there are 96 hospices participating.
The model is being phased in over 2 years and participating hospices were randomly assigned to one of the two cohorts. The first began providing services to beneficiaries in January of 2016, and the second began in January of 2018. MCCM will end for all participating hospices in December of 2020. Participating hospices are required to report their performance on set quality measures including beneficiary medical utilization. The evaluation portion of the model will take another 2-3 years beyond 2020 to complete.
C-TAC supports this model as an example of needed innovation in the care for those with advanced illness. Allowing people to continue treatments they want, such as dialysis and will increase access to hospice and provide much needed support to more patients and their families.