Currently, Medicare patients that wish to receive palliative hospice care have a tough choice to make—forgo any curative treatment or incur all hospice care costs. This could change, however, with the recent launch of CMS's Medicare Care Choices Model ("MCCM"). CMS is currently accepting applications for the MCCM, a three year demonstration project under which eligible beneficiaries can receive certain types of services from participating hospice providers while concurrently receiving services from their regular, curative care providers. Central to the MCCM is hospice providers' continued active role in care coordination and case management.
Eligibility to Participate in the MCCM
Only Medicare certified and enrolled hospice providers are eligible to participate in the MCCM. Further, any Medicare and certain dual-eligible beneficiaries who wish to participate, in part: (1) must be diagnosed with terminal cancer, chronic obstructive pulmonary disease, HIV, or congestive heart failure; (2) must not have elected the Medicare or Medicaid Hospice Benefit within 30 days of participation in the MCCM; and (3) otherwise meet the Medicare hospice benefit eligibility and admission criteria.
The Role of the Hospice Provider
Participating hospice providers are expected to engage in the following:
Care Coordination. Hospice providers must coordinate care within the participating hospice as well as between the hospice and a beneficiary's curative providers. Further, hospice providers must (i) manage the beneficiary's pain and other symptoms and (ii) engage in shared decision-making between the beneficiary, family, and the beneficiary's providers. The MCCM still requires hospice providers to establish a plan of care as currently required by the Medicare hospice Conditions of Participation; however, hospice providers must also complete a patient-centered goals plan within three days of the beneficiary's enrollment in the MCCM. This plan must be reviewed and, if necessary, revised at least every 15 days, as needed based on the beneficiary's condition, or as requested by the beneficiary.
Ongoing Communication. Hospice providers must communicate with the beneficiary regarding the beneficiary's goals, treatment plans, and treatment options. While beneficiaries are still seeking curative care, the need for face-to-face encounters with hospice providers will be limited—hospice providers will function more as a source of information. As a result, the MCCM expects providers to educate beneficiaries on available hospice support services.
Quality & Data Reporting. Hospice providers must submit to CMS a monthly log of services and activities provided to beneficiaries in accordance with their plans of care. CMS may randomly audit these logs through the MCCM period to compare beneficiaries' plans of care with the providers' service and activity log. On a quarterly basis, hospice providers must also submit to CMS data on certain quality measures. These quality measures will include those selected for the Hospice Quality Reporting Program as well as other measures focused on pain management, care coordination and case management, care transitions, communication, patient-centered goals, and patient and family satisfaction.
Under the MCCM, CMS will pay participating hospice providers a fee, which constitutes the total reimbursement for MCCM services and includes all services available under the Medicare Hospice Benefit for routine home care and inpatient respite levels of care that cannot be billed separately under Medicare Parts A, B, and D. Hospice services covered under the MCCM do not include general inpatient or continuous home care levels of hospice care. Participating hospice providers will receive $400 per beneficiary per month for providing services for 15 or more days per calendar month or $200 per beneficiary per month for less than 15 days. No providers, including any primary care providers, can bill the beneficiary for any care coordination or case management services. However, because participating beneficiaries do not receive the Medicare Hospice Benefit, providers can bill Medicare for drugs, durable medical equipment, therapy services, and ambulance transports normally covered through the Medicare hospice per diem in addition to any curative services received.
What Providers Should Know
CMS is currently accepting applications from hospice providers that wish to participate in the MCCM. Applications are due June 19, 2014, and information regarding the application's contents can be found here. CMS expects to announce participants by fall of 2014.
In selecting participants, CMS indicated it will give preference to those hospice providers that can demonstrate mature and effective relationships with curative care providers and have experience developing, reporting, and analyzing quality data.
CMS's demonstration projects, such as the MCCM, can give providers insight into what CMS may expect in the future. The MCCM encourages hospice providers to take a lead role in coordinating all types of end-of-life care. Those hospice providers that already have or can gain experience coordinating with curative care providers will be ahead of the game. However, given that hospice providers are in the position to gain referrals from curative care providers, hospice providers must ensure that these relationships remain compliant with federal and state fraud and abuse laws.