Will Medicare finally allow Americans on dialysis to access hospice without hastening death? Year 2022 is just around the corner, and that’s when Medicare begins full implementation of it’s delayed and much anticipated Kidney Care Choices model (KCC). Traditionally, Medicare has required beneficiaries to give up life-sustaining dialysis to access hospice. Medicare’s new Kidney Care Choices model offers hope for an end to this practice, but perhaps just a glimmer.

Does Medicare Require People To Give Up Dialysis For Hospice?

Yes. Medicare refuses to pay for dialysis and hospice concurrently. Medicare only pays for hospice when patients no longer have a reasonable option for a cure or when patients no longer want to pursue aggressive treatments. Unfortunately, Medicare continues to miscategorize dialysis as a cure, making dialysis patients ineligible for the same hospice benefits that people with other diseases receive. Of course, dialysis does not cure kidney failure any more than insulin cures diabetes. Medicare does not force diabetics to give up insulin for hospice. Medicare’s dialysis-hospice rule runs against the hospice philosophy. Hospice does not seek to shorten or prolong life. Hospice seeks to improve quality of life during an important time. However, the severe symptom relief hospice delivers is usually associated with survival lengthened by days to months.

National and Personal Costs of Medicare’s Dialysis-Hospice Rule

A study published recently in the Journal of the American Medical Association shows that people on dialysis use hospice much less than the general population (27% vs 48%). People with ESRD also receive hospice less than people with other organ failure diseases. Medicare’s unique exclusion of life-sustaining care for kidney failure patients has led to needless personal suffering for nearly 100,000 Americans each year. The classification of dialysis as curative also increases costs for taxpayers. Among dialysis patients specifically, hospice cuts Medicare spending by more than two-thirds, lowers hospitalizations 53%, and lowers intensive care procedures 90%.¹

How Can Hospices Prepare for Medicare’s Kidney Care Choices?

1. Identify Centers Participating in the Kidney Care Choices Model

The first thing for hospice agencies to understand when preparing for Kidney Care Choices is that hospices do not participate in it. The program allows nephrology centers, dialysis facilities, and ESRD healthcare practices to voluntarily accept bundled payments. These practices have the option to partner with the hospice agencies they choose and pay them out of their bundled reimbursement. There is no freedom of choice in this arrangement, so practices can choose to only work with their own hospice. At best, they will likely choose to work with a limited number of community providers.

2. Collaborate with the Kidney Care Provider to Demonstrate Value

KCC’s bundled reimbursement does not increase when hospice is elected. Hospice traditionally lowers overall costs for Medicare by reducing intensive care procedures and hospitalizations, neither of which creates immediate savings for the KCC provider. Medicare proposes that if overall costs go down for their patients, benefits will go to the provider later. Writing for the Clinical Journal of the American Society of Nephrology, Jane Schell and Douglas Johnson express concern that most nephrology providers will choose to avoid this gamble. Hospice agencies should sit down with KCC providers, examine the costs covered by the bundled KCC reimbursement, and look for ways hospice can reduce those expenses. Medicare designed the bundled reimbursement to cover Chronic Care Management Services (CPT 99490), Advance Care Planning (CPT 99497-99498), and Transitional Care Management Services (99495 – 99496). Are there cases where hospice can manage some of those services more cost-efficiently than nephrology without hospice?

A More Effective Way for Hospices to Serve Patients on Dialysis

In practice, where hospice is concerned, Medicare’s Kidney Care Choices is likely to have a small effect. A limited number of centers, working with a small number of hospice agencies, under constrained reimbursement that does not realistically include hospice services does not bode well for the hundreds of thousands of Americans on dialysis who may one day want to have the same hospice options as other Americans.

Hospice agencies are more likely to serve a greater number of patients on dialysis through the primary diagnosis loophole. Referral source education programs to make doctors and discharge planners aware of this loophole may increase referrals. In 2014, Medicare ruled that dialysis would be considered palliative, not curative, if the primary hospice diagnosis is not end-stage renal disease (ESRD). For instance, a patient who has both ESRD and cancer could receive Medicare reimbursement for dialysis and hospice concurrently, if the hospice plan of care lists cancer as the primary diagnosis and ESRD as a secondary diagnosis. 

Reference

1. Wachterman MW, Hailpern SM, Keating NL, Tamura MK, O’Hare AM. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Internal Medicine. 2018 June; 178 (6): 792-799.