Medicare Compliance & Reimbursement

Should patients with these diagnoses be included in the MCCM project, too?

Although most provider organizations — especially those in the hospice and palliative care sectors — are optimistic about the Medicare Care Choices Model (MCCM) project, some industry watchdogs are more cautious. Here are some potential areas of confusion that you should consider when providing services to patients who are participating in the model.

“The goal of the model is laudable, but given its design, it’s not likely to achieve success and may possibly cause confusion and even harm,” laments the Center for Medicare Advocacy (CMA). CMA believes that the MCCM project could create confusion in three key areas:

1. Confusion over the law — The Centers for Medicare & Medicaid Services’ (CMS’) description of the MCCM project is misleading because it hints that beneficiaries who elect the hospice benefit waive Medicare coverage for all curative treatment, which is false, CMA says. “When Medicare beneficiaries elect the hospice benefit, they waive Medicare coverage for curative treatment only for their terminal illness.”

For example, if a Medicare beneficiary who has diabetes and hypertension elects hospice care because she’s also diagnosed with terminal liver cancer, Medicare will stop paying for curative care for the terminal liver cancer, CMA explains. But Medicare will continue to pay for all care related to the beneficiary’s diabetes and high blood pressure.

2. Confusion about treatment goals — The term “curative care” is misleading as well, because it indicates that such care will cure a disease, CMA notes. But given the selected disease categories for the study (advanced cancers, COPD, HIV/AIDS and congestive heart failure), “it is very unlikely that any treatment will cure the terminal illness.”

“So it seems that in using the word ‘curative,’ CMS really means that it will continue to pay for treatment that might extend the life of a person living with a terminal illness,” CMA clarifies. For instance, the MCCM “might allow someone with end-stage lung cancer to receive hospice care while simultaneously receiving chemotherapy that will not cure her cancer, but might lengthen her life.”

3. Confusion about when curative treatments are best — For some of the eligible diseases under the MCCM model, including advanced lung, pancreatic and colon cancers, research indicates that patients actually live longer if they forego curative treatment and receive hospice care only, CMA notes. “So encouraging ongoing treatment may in fact not be in the best interest of many beneficiaries with the selected diagnoses.”

Certain diagnoses that could greatly benefit from the model are not included in the project, however — these include Alzheimer’s disease and other dementias, as well as End Stage Renal Disease (ESRD), CMA says. For instance, patients who have ESRD rely on dialysis to stay alive and will die if they stop dialysis. But until they decide to stop dialysis, ESRD patients cannot access hospice care.