Eli's Hospice Insider

Entry barriers limit demonstration.

The recent revelation that one-quarter of hospice agencies have withdrawn from Medicare’s concurrent care hospice demonstration project speaks volumes about how the demo is going.

Hospices “successfully implemented” the Medicare Care Choices Model, which allows hospice-eligible beneficiaries to receive care from hospices while still seeking curative care. “But enrollment was lower than expected,” demo contractor Abt Associates says in a new report evaluating the program thus far. “Due to low enrollment, it is too early to measure any impacts MCCM has on outcomes at the end of life,” Abt adds in the report.

History: The Centers for Medicare & Medicaid Services implemented the MCCM demo in January 2016, with about half of the 141 participating hospices starting on that date and the other half set to start in January 2018. To qualify for the program, CMS started out requiring benes to have two hospitalizations in the previous 12 months, at least 24 months of Medicare eligibility before the program began, Part D enrollment, three physician visits related to the MCCM-qualifying diagnosis (AIDS, CHF, COPD, or advanced cancer) in the prior 12 months, no managed care enrollment, and living at home (not in a nursing home or other facility), among other things. CMS estimated as many as 150,000 beneficiaries would join the five-year model.

Trouble enrolling beneficiaries for the program was apparent almost immediately. In a March 2017 National Association for Home Care & Hospice March on Washington conference, one attendee told a top CMS official that finding an eligible MCCM patient was like “finding a unicorn.”

CMS quickly eased some of its requirements for patient participation, changing the two-hospitalization requirement to one hospital encounter of any type (including observation stays or emergency room visits with no admissions) and dropping the Part D criteria. As of January 2017, CMS also dropped the 24 months of previous Medicare enrollment down to 12 months and allowed three physician visits for any reason.

But problems enrolling beneficiaries persisted, the new report shows. From January 2016 through June 2017, only 1,092 eligible beneficiaries enrolled in the model. Eighteen hospices withdrew from the first demo group and 19 dropped out of the second group. Another eight hospices were planning to withdraw as of early 2018, the report adds.

Difficulty recruiting patients for MCCM was a major reason for withdrawal, Abt indicates. The 12-month Medicare eligibility and non-managed care enrollment were most often cited as the criteria limiting enrollment, according to the report.

Hospices listed problems with almost all of the other criteria as well, including with securing a certification of terminal illness from a physician for diseases like COPD. Having “costs greater than the $400 per beneficiary monthly payment; data-reporting requirements; and the complexities of coordinating medications and durable medical equipment (DME) for MCCM enrollees,” were also listed. “MHB covers medications and DME, but MCCM does not,” the report points out.

Bright side: “Hospice staff, referring providers, and MCCM enrollees generally expressed high levels of satisfaction with the concept of MCCM,” the report notes.

“There was tremendous interest among hospice providers as the MCCM model was introduced,” notes Edo Banach, CEO of the National Hospice & Palliative Care Organization. Enrollment may be low, but “with valuable lessons learned, NHPCO is looking forward to working with CMS to build upon MCCM in the years ahead,” Banach says.

Remember: “Hospice itself started as a demonstration,” Banach tells Eli. “The value of any demonstration is that it helps us hold a mirror up to our assumptions and to support broader change in the Medicare program.”

Note: See the 298-page report at https://innovation.cms.gov/Files/reports/mccm-firstannrpt.pdf.