Vague proposal about to become more specific
Hospices will test new service packages
MediCaring, an ambitious but vague proposal to reform Medicare, is about to become more specific. The proposed reform would divert reimbursement for chronically ill patients who are expected to take their own lives into new packages of supportive services. And while some hospices may have feared that it could supplant hospice care by offering a broader array of end-of-life services for longer than hospice’s mandated six-month window, it now appears that leading hospice executives will be participating in MediCaring’s design and testing. (See Hospice Management Advisor, June 1997, pp. 68-69.)
About 50 representatives from hospices, HMOs, other health care providers, the Veterans Administration, the Health Care Financing Administration (HCFA), and the Center to Improve Care of the Dying at George Washington University in Washington, DC, MediCaring’s developer, will meet Nov. 5 and 6 in Washington to begin exploring implementation issues. These include:
• service mix;
• eligibility;
• reimbursement levels;
• Medicare waivers.
But the project is definitely on the fast track, with the goal of launching 10 to 15 demonstration sites by the fall of 1998, explains center senior scientist Anne M. Wilkinson, PhD.
Created by the center’s director, Joanne Lynn, MD, MediCaring was said to be an influence on draft legislation, the Compassionate Care Bill, introduced in Congress earlier this year by Sen. John D. Rockefeller (D-WV). According to an unpublished position paper by Lynn and Wilkinson, Medicaring "would focus on comprehensive, supportive, reliable community-based services, shaped by preferences, with priorities of symptom management and family counseling and support."
Let’s do it right
By carving out the seriously, chronically ill patient population and shifting Medicare resources away from invasive, potentially futile medical interventions toward home and community-based supportive services, MediCaring proposes to manage patients with serious fatal chronic illnesses more appropriately at the same or less cost. However, unanswered questions about service arrays and configurations, severity thresholds, appropriate diagnoses, and funding mechanisms will have to be explored in the demonstrations the center hopes to launch next year. "We don’t have all the answers. We need providers to tell us how to do it right," Wilkinson says.
Where does hospice fit in these plans? "Services could be similar to hospice, but extended out longer than six months," and thus would have to be less intensive and costly than hospice’s current service package, costing $95.77 per day for routine home care, Wilkinson says.
MediCaring offers an "opportunity to change the character of hospice and reconfigure hospice services," for patients in the last phases of life. Hospice already serves cancer patients well, but MediCaring is an opportunity to do something different for patients with chronic heart and lung diseases or dementias, for example.
"We’d like to work with hospices," Wilkinson adds. "The question for hospice is: Do you want to be the provider of care to all of those patients in the larger group or remain a niche player? You have an opportunity to be leaders. Now’s the time to seize the agenda."
The November MediCaring meeting aims to gather information on what innovative providers are already doing to care for seriously ill patients but also to secure commitments from 10 to 15 potential demonstration sites representing different models of care. These providers then need to "go back and make it happen," using techniques for rapid system change developed by the Institute for Healthcare Improvement’s Breakthrough Series on Improving Care at the End of Life. (See Hospice Management Advisor, September 1997, pp. 100-102.). Lynn is also directing that project, and several of its hospice participants will also be attending the November MediCaring organizing meeting.
The project also needs to avoid the appearance of rationing life-saving medical care to the elderly by emphasizing, instead, the goal of providing more appropriate care, Wilkinson says. Funding must come largely from the Medicare waivers, since the goal is to be lean, efficient, and at least budget neutral, but foundation support will be needed for coordination and evaluation. Also planned are a Capitol Hill hearing on end-of-life care sometime next March and meetings with other national stakeholders. HCFA has offered a letter of support, and expressed its interest in working as a partner on the project.
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