Medicare Part E?

Congress first created the Medicare hospice benefit in 1982. During the first full year after the law went into effect, only 200 Medicare patients enrolled in hospice, accounting for less than one-half percent of the deaths that year. By 1986, seven percent of Medicare patients who died were enrolled in hospice at the time of death; in 1998, it was 19 percent and in 2013 it reached 47 percent. A new report from the National Hospice and Palliative Care Organization shows this percentage has remained fairly stable: in 2017, it was 48 percent.

The length of time that Medicare patients are actually enrolled in hospice remains woefully short, particularly for some diagnoses: while the average length of stay is 71 days, reflected a few very long stay patients, the median length of stay is only 24 days. In fact, fully 28 percent of individuals got between one and seven days of care, far less than most clinicians regard as optimal. Patients enrolled in hospice because of a cancer diagnosis tended to have the shortest lengths of stay in the program. Nonetheless, the historical shift towards hospice as a reputable and popular approach to end of life care demonstrates that we can introduce a new Medicare benefit package and expect it to catch on. The same happened with Medicare Part D, the drug benefit (though this was an add-on rather than a substitution), with enrollment going from 52 percent in 2006 to 71 percent in 2016. Medicare Part C, the partially privatized HMO-style benefit now known as Medicare Advantage, has also taken off: in 2003, only 13 percent of Medicare beneficiaries opted for such a plan but by 2017, 33 percent did. 

The time is ripe for adding a new alternative benefit package to Medicare’s offering: whether we call it Medicaring, the name preferred by Joanne Lynn, Director of the Elder Care and Advanced Illness division of the Altarum Institute,

or Intermediate Care, my term, or something else, it would provide enhanced home care services for frail elders and others with advanced illness in exchange for limitations on access to intensive, expensive, burdensome, and seldom beneficial treatments such as bone marrow transplantation or open-heart surgery. 

Americans tend to dislike or at least be very skeptical about any kind of limits to care. But often the problem is that we focus on what people cannot have rather than emphasizing what they can have—and what they often need and want. In fact, I think one reason that patients only enroll in hospice very late in the course of their illness is that hospice is presented as the withdrawal of care, the discontinuation of care, rather than as the substitution of one approach to care for another. Many patients may be unwilling to forgo treatment altogether, which is how hospice is frequently presented, but are eager to choose a less invasive, less burdensome form of care: infusions of very toxic chemotherapy drugs in the physician’s office every week or two may be rejected if there is an oral medication they can take at home that has far fewer side effects. But if the only alternative is certain death, chemotherapy looks far more attractive.

Important and interesting work has been done on developing and implementing programs to care for people with advanced illness or frailty, such as the Coalition to Transform Advanced Illness Care's 2017 report. The way forward is now to create a Medicare benefit to accommodate this approach.

Making Dollars and Sense with MediCaring

For roughly 20 years, a proposal to offer a new Medicare benefit for frail older people has gradually been building momentum. Named Medicaring, it's the brainchild of the pioneering geriatrician and palliative care physician, Dr. Joanne Lynn. Now, the Altarum Institute, where Dr. Lynn is the director of the Center for Elder Care and Advanced Illness, has launched "MediCaring Communities." Lynn and colleagues describe this new, revised model and offer a simulation to show how it could play out in practice in an article in the Milbank Quarterly. The bottom line is that the concept not only makes sense, but it also makes dollars and cents.

The basic premise is that we still do a poor job of caring for frail elders, exactly what I repeatedly argue in my blog posts: we prescribe the wrong medications, subject frail elders to too many tests, and provide treatment that makes sense for people with just one medical condition, not for people who are very old, have multiple chronic conditions, and suffer from impairments in their daily activities. As a result, frail elders are often hospitalized, where they develop delirium and falls and endure incontinence and iatrogenesis. If this state of affairs wasn’t bad enough, all this costs a fortune.

In response, the proponents of MediCaring Communities argue that we should instead address frailty by providing “reliable, supportive services and a care plan that reflects the frail person’s situation and priorities.” This is best achieved by integrating supportive services (transportation, social services, and housing) and medical care and by replacing some of the most expensive and burdensome medical services with additional support services. Those who would be eligible for this program would either be over 65 and have at least 2 areas of physical limitation (or dementia) or over 80, regardless of limitations. In addition to incorporating health, social, and supportive services, a community board would monitor and revise the program. And each participant in MediCaring would have a longitudinal care plan that reflects his or her personal goals of care.

The authors simulated how this program would unfold in 4 different communities, reflecting diverse environments: Akron, Ohio, Milwaukie, Oregon, Queens, New York, and Williamsburg, Virginia. Working with leaders in each area, 4 separate plans were developed that varied in the details of their operation but were similar in the overall strategy. What they found was that all 4 communities would generate substantial savings every month for each enrolled beneficiary. These savings would arise from reductions in inpatient hospitalization, decreased use of skilled nursing facilities, and lower use of long term nursing home care. In Queens, for example, the monthly savings per enrollee would total $250 in the first year, but rise to $537 by the third year. Cumulative net savings from the 4 communities was projected to be about $11 million by the end of the second year and $31 million by the end of the third year for the 15,500 eligible patients.

For MediCaring to work in practice, CMS would need to grant waivers to bypass various regulations that govern current Medicare provider organizations. But most important—and most challenging—it would require older people to be identified as frail (an estimated 10 percent of the population over age 65 is frail, with that percentage rising with age) and it would require that frail patients and their families accept the tradeoffs that underlie MediCaring. Is that a realistic possibility in this era where people don’t want to think about declining health and don’t want to limit their options?

The good news is that 42 percent of Medicare beneficiaries are enrolled in hospice at the time of their deaths--and hospice, like the proposed MediCaring program, demands tradeoffs. It's taken 30 years to reach the current level of participation: in 1987, 4 years after the hospice benefit was first introduced, only 7 percent of older patients were enrolled in hospice at the time of their death. But still today, many people only enter hospice in the very last days of life, too late to derive maximal benefit. Nonetheless, Americans gradually came to understand that their needs changed as they entered life's last phase and that hospice provides more of what they need and less of what they don't than conventional Medicare. We need to help older people and their families reach the same conclusions about MediCaring.