Bill would give physicians lead on advanced illness care

Joseph BurnsPhysicians, not the federal government, should decide what’s best for patients with advanced illnesses or who are close to death, according to a bill before the U.S. Senate.

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The bill would allow Medicare to establish 20 “advanced care collaboratives” of healthcare providers and community-based social service organizations in a demonstration project to test alternative forms of care for patients who are dying or who have serious advanced illness. The bill also addresses the hurdles physicians face when putting patients in hospice care.

In June, Senators Sheldon Whitehouse (D-Rhode Island) and Elizabeth Warren (D-Massachusetts) introduced the Removing Barriers to Person-Centered Care Act of 2016. The U.S. Senate’s Special Committee on Aging referred the bill to the chamber’s Committee on Finance, where it has remained. Whitehouse hopes to move it out of committee for a vote next year. 

“For years, Rhode Island patients and providers have told me over and over that certain Medicare rules and regulations make it difficult to treat patients with advanced, serious illness in the right setting at the right time,” Whitehouse tells Medical Economics. He says the bill would reduce unnecessary and costly treatment now required under rules from the Centers for Medicare & Medicaid Services (CMS) by encouraging better coordination of care among physicians and community  social service agencies, he added. 

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For example, CMS requires a three-day inpatient stay before a patient can move to hospice care, says David Grube, MD, a retired primary care physician. “If I had a patient who was too sick to stay home but not so sick that she needed to be in the hospital, the ideal place of care would be a nursing home or a skilled nursing facility,” says Grube. “But under Medicare rules, that patient couldn’t go into a nursing home or a [skilled nursing facility] without first paying out-of-pocket for a three-day hospital stay.” 

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Requiring a three-day hospital stay before Medicare will pay for a transfer to a nursing home or skilled nursing facility is counter to the ideal of providing optimal patient care, adds Grube, who volunteers for Compassion and Choices, a Denver, Colorado, nonprofit  that works to improve care for the terminally ill. When a patient can’t afford to pay for a three-day stay, physicians often have no way to get the care that patient needs, he says.

“Patients make decisions based on how much the care will cost rather than what’s best for them. There are horror stories all around about people who end up losing everything they have before they can get the care they need,” Grube says.

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Under current regulations, a patient being treated for a terminal illness cannot go into hospice without first stopping all other treatment. 

“What we need is a transition benefit so that when it becomes clear that treatment is not working well, the patient can begin to get hospice care while physicians continue to treat the patient’s illness,” Grube explains. “You shouldn’t have to stop all treatments just to move into hospice.” 

If Congress passes the bill next year and it’s signed into law, applications for the collaboratives would be accepted in 2018 and contracts for the collaboratives would be signed in 2019 or later. But Medicare could implement elements of the program sooner, Whitehouse says.  

Joseph Burns is a journalist in Falmouth, Massachusetts. How can Medicare improve access ? Tell us at medec@ubm.com.