Hospice care and curative care together MCCM

CMS will start a 5 year program called Medicare Care Choices Model or MCCM at 141 hospice agencies in 2016.

CMS originally anticipated selecting 30 Medicare-certified hospices for the project but given the overwhelming interest from the U.S. hospice community, the list of MCCM demonstration sites grew to the current 141.

One of the biggest problems with hospice is that people will not avail themselves of the service because they are not ready to give up hope for a cure. The average length of stay in a hospice remains shorter than it should be, to the detriment of hospice care recipients.

From the agencies point of view, the most intense patient needs are at the beginning of service and the end of life. If these two come very close together, the agency doesn't have the time to establish the rapport that becomes so crucial for the family as the end nears. CMS is also looking to address this with a U shaped payment model.

Hospice remains the highest quality and lowest cost way to approach end-of-live issues. Any program that increases hospice usage and length of stay is a step in the right direction.

Bundled payments for joint replacements

CMS is proposing to pay health systems a fixed amount for all care related to knee and hip replacements.

From the proposal:

The hospital where the hip or knee replacement takes place would be held accountable for the quality and costs of care for the entire episode of care - from the time of the surgery through 90 days after discharge.
As a result, hospitals would have an incentive to work with physicians, home health agencies, and nursing facilities to make sure beneficiaries get the coordinated care they need, with the goal of reducing avoidable hospitalizations and complications.
(Italics mine)

In 2013, Medicare spent more than 7 Billion dollars in hospital costs alone related to these procedures.  Clearly, they recognize the savings that occur if the three sectors of health care, Hospitals, Physicians, and Healthcare at Home all work together.

I have long advocated better coordination between Healthcare at Home and the other sectors.  In 75 different geographic regions, that coordination is going to be crucial to the financial well being of the health systems.

Healthcare at Home - the undervalued sector of healthcare

Homecare, Hospice and Tele-Monitoring have been deeply undervalued in our modern medical system. So much so that there isn't even a good name to use when talking about them.  "Post-acute care" is not right - there is so much that can and should be done before (or instead of) a hospital stay. There is some movement lately toward the term "Healthcare at Home".  Seems like an apt description.  The twitter hashtag #healthcareathome shows it as the name of a home care company in India, which may limit its use in the US.  But I'm going to follow the lead of NAHC, as eloquently described in a recent Home Care Technology Report.

Although I have long advocated that home care and hospice need to be part of strategic thinking, health enterprises still not embracing these care delivery systems.  Why is that?

1. Traditional payment for these services has been different than hospitals and physicians are used to.Home care is paid a fixed amount per 60 days of care delivery, regardless of number of visits.
   Hospice is paid a per diem rate, with four different rates based on patient acuity.Essentially, Healthcare at Home has been out of the fee for service business for over a decade!
2. Healthcare at home revenue is small percentage of the system budget
   Just as football and basketball tend to occupy most of an athletic director's energies, Cardiac and Orthopedic surgery departments tend to occupy most of a system CFO's energies.  Time follows money.
3. Clinicians and patients are not in the same building as administration
   Even the most enthusiastic "management by walking around" won't get to the strip mall down the street where the home care agency is, and the patients are spread all over the county.
4. Care delivery is not curative
   Hospice care by definition is not curative (even though there are pilot programs coming up that will allow curative care concurrent with hospice), and home care is mainly teaching patients and caregivers.  The benefits of healthcare at home are in improved quality of life, and allowing patients to remain where they want to be, not in recoveries.  It's not glamorous, but it is good care.

So given all of that, why should Healthcare at Home be part of a health enterprise's strategy?

1. Payment systems are changing
   Healthcare at Home has not been fee for service for a long time.  These services already know how to deliver quality care at the lowest possible cost.
2. Revenue will no longer be attributable to specific functions
   Under value based pricing, entities are paid for quality care delivery and outcomes, not services performed.  Home Care and Hospice can improve care delivery and outcomes, and at less cost than other care delivery mechanisms.
3. Location is less important
   The rise of remote visits, the vast expansion of satellite facilities, and even health kiosks are all signs that the most efficient care delivery does not happen in the largest, nicest building on a health care campus.
4. Outcomes are not always about cures
   The savings from hospice are extremely well documented, as is the amount of money spent in the late stages of care, frequently with no good effect.  Patients consistently say they want to stay at home, even as their health may be fading.

CMS has at least two proposals moving things in this direction:

• CMS is proposing bundling payment for joint replacement care.  My thoughts.
• CMS will let 141 hospice agencies care for patients while they continue to receive curative care.  My thoughts.

Both of these proposals show the largest payer in healthcare is also beginning to recognize this sector as undervalued.