tag:blogger.com,1999:blog-3672496731205380327.post6760665509652795951..comments2024-03-26T20:43:17.849-04:00Comments on freeforall--a health policy discussion: Getting the Incentives StraightDon Taylorhttp://www.blogger.com/profile/16141749812035072101noreply@blogger.comBlogger9125tag:blogger.com,1999:blog-3672496731205380327.post-24231202316986460882013-06-02T22:14:58.985-04:002013-06-02T22:14:58.985-04:00I support the U shaped payment structure that MEDP...I support the U shaped payment structure that MEDPAC is supporting for hospice reimbursement.<br />- Zack with www.hospicebasics.com - All About Hospice CareAnonymoushttps://www.blogger.com/profile/05600797838136554923noreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-76329480975066776852011-02-07T18:25:02.431-05:002011-02-07T18:25:02.431-05:00Cordt:
MEDPAC certainly wants a U shaped payment a...Cordt:<br />MEDPAC certainly wants a U shaped payment approach (higher per diem in first few and last few days). This make sense to me (the shape of the payment), though I am unsure of what the payment levels should be. I assume the rates will be based on cost finding studies. I would do that and up the scrutiny of long stay patients I guess. However, I am not sure any change in hospice payment is inevitable in the 112th Congress... For me, a move to concurrent care is a large priority, because thy lingo of stopping curative and starting hospice doesn't make much sense (if you could cure it you would).Don Taylorhttps://www.blogger.com/profile/16141749812035072101noreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-21763411127257325222011-02-07T16:15:13.324-05:002011-02-07T16:15:13.324-05:00Don- Adding quality of care to discussions of hosp...Don- Adding quality of care to discussions of hospice payment reform is necessary, although it appears at least some significant hospice payment reform will move forward before additional quality data is available. It also appears that MedPAC recommendations target the entire industry (i.e., they do not target hospices based on incorporation status, particular states, etc.). So using currently available data, what hospice payment criteria do you believe would incentivize increasing hospice median LOS (addressing problems with short LOS), while decreasing WFA (addressing problems with long LOS)? Some thoughts include: strengthening the hospice aggregate cap definition, calculation, and repayment process; considering the percentage of hospice patients discharged alive; defining and surveying volunteer and bereavement requirements more carefully; more closely examining the location where hospice is provided (home, nursing facility, inpatient unit); and strengthening fraud and abuse measures. Your thoughts? Thanks-<br />CordtCordt Kassnerhttp://www.hospiceanalytics.comnoreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-55046851978531119492011-02-04T20:40:33.410-05:002011-02-04T20:40:33.410-05:00@Brad F:
you are correct that we didn't match ...@Brad F:<br />you are correct that we didn't match or account for different practices across hospices. From standpoint of determining cost to Medicare, the different practices across hospices don't matter, at least directly, because Medicare pays per diem amount....then hospices have lots of discretion as you note. The definition of cost to Medicare is what Medicare paid. The different practices of hospice could have big effect on quality, which could affect lifespan which could indirectly effect cost. Different practices could also effect profitability. <br /><br />Also, one argument for large hospices is that they have more scope to do certain types of care that may help a patient but which is very expensive relative to the per diem. <br /><br />I will send you some of the protocols when we get closer for how we plan to measure quality, as I would be interested in getting your perspective and insight. thanksDon Taylorhttps://www.blogger.com/profile/16141749812035072101noreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-12464861841564844792011-02-04T20:15:17.687-05:002011-02-04T20:15:17.687-05:00Just to chime in again, hospices offer different l...Just to chime in again, hospices offer different levels of service (they are not all the same--some will administer certain drugs, others wont, etc), nurses invariably screen at bedside and want documentation certifying eligibility from the referring doc, and it is possible the FP and NP centers are simply attracting different types of patients, albeit ones whose characteristics we are not adjusting for in the propensity scores.<br /><br />Thanks again,<br />bradAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-56935550246884397192011-02-04T14:00:51.532-05:002011-02-04T14:00:51.532-05:00@Christopher Langston. I hadn't thought of th...@Christopher Langston. I hadn't thought of the idea that short stay hospice could be viewed as hospitals 'dumping' patients to hospice...under prospective payment hospitals get fixed amount based on diagnosis, so sending someone to hospice halfway through avg. hosp LOS could maximize profit for a hospital...it could also be what is best for the patient. Can't really sort that out with these types of data. <br /><br />I agree that more effort needed increase shorter/median LOS should be a priority. Finally, the hospice benefit generally needs to be modernized; the language of curative doesn't make so much sense (we would cure it if we could). Hard to let the best policy be front and center on EOL in the current political climate though. Concurrent care is the next step...Don Taylorhttps://www.blogger.com/profile/16141749812035072101noreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-74566271922833096992011-02-04T08:38:25.443-05:002011-02-04T08:38:25.443-05:00Don - I couldn't agree more. The problem poli...Don - I couldn't agree more. The problem policy makers seem to be focused on is the long "stay" outliers, when the short stay outliers are at least as big a problem, if not more. The Wachterman, Marcantonio, et al paper in JAMA give us reason to be suspicious of some long stay cases, especially because there are more of these long-stay cases in for-profit than not-for-profit hospices. For example for LOS >=365 days, for profits had 6.9% of cases and not-for-profits had 2.8% of cases. The suspicion might be that the difference represents the inappropriate bias of for-profits to take advantage of the per diem -- in 4.1% of cases. <br /><br />I think the bigger news is that in the <7 day LOS category not-for-profits have 34.3 % of their cases and for-profits have 28.1% of cases. From my sense of the clinical QOL benefits of the hospice model, I don't think anyone can have much benefit in that length of time. <br /><br />In fact, while a hospice may not profit from a really short case (where they can't make up the up-front costs), I am suspicious that hospitals may be "profiting" by using hospice as a way to discharge a patient, reducing hospital costs, but in ways that leave no real potential clinical benefit to the patient.<br /><br />Anyway, looking at these data, I think the most urgent policy matter is to get the median LOS up. I think that the most simple minded intervention should be tried. Instead of requiring an MD to certify that someone will die within 6 months, lets try 9 or 10 months and see what happens. I'm not sure it will reduce the number of short stays, but I also don't see any reason to think that it will extend the number of very long stays.Chris Langstonhttps://www.blogger.com/profile/03826452039424712299noreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-28281306989510789562011-02-03T20:52:42.595-05:002011-02-03T20:52:42.595-05:00Brad
In one sense, the reason hospice can 'sa...Brad<br /><br />In one sense, the reason hospice can 'save money' is because the 'control group' is so expensive. In our paper, if you look at last 365 days of life, costs are about same for hospice v. those not dying in hospice. We used propensity score matching because is a choice and not random. Then we took hospice entrance and compared from that day to death for the hospice decedent and two controls who were similar but didn't use hospice. The savings are from the point of hospice entry. The biggest savings are in the last 7-10 days of life because hospice folks tend to avoid the last hospitalization. Our study sample was all deaths, so someone doing 'self hospice' meaning die at home with little care could have been in the control group if similar in terms of diagnosis and other observables. So, a low use community with no hospice could spend more with access to hospice. And hospice users using such care longer than ~125 days or so cost more than non hospice from point of hospice election to death. So, long periods of hospice use to cost more for Medicare.<br /><br />Real question would be if you went to concurrent care (start hospice without unelecting curative)...there are two studies that still show savings but many (MEDPAC, CMS) don't believe it I don't think.Don Taylorhttps://www.blogger.com/profile/16141749812035072101noreply@blogger.comtag:blogger.com,1999:blog-3672496731205380327.post-64498425540447411432011-02-03T20:25:00.951-05:002011-02-03T20:25:00.951-05:00Don
Does your work in evaluating hospice savings t...Don<br />Does your work in evaluating hospice savings take into account the potential denominator of eligible hospice patients?<br /><br />By that I mean, costs savings (put aside QOL for this question) are relative to churning in an acute stay hospital, and SNFs? <br /><br />Could a hospice "enlightened" community, that was once use to dying at home with suboptimal services (read: low cost) suddenly see the light, and ramp up use.<br /><br />I am envisioning a Mcaid/CHIP scenario to boost child enrollment. I know not apples to apples, but you get the picture. Suddenly, the comparison group is not acute care vs hospice, but die at home (low cost "bad death") vs hospice?<br /><br />thanks<br />BradAnonymousnoreply@blogger.com