Paying for Palliative Care in Medicare: Evidence from the Four Seasons/Duke CMMI Demonstration.

CONTEXT: Palliative care improves patient and family outcomes and may reduce the cost of care, but this service is underutilized among Medicare beneficiaries.

OBJECTIVES: To describe enrollment patterns and outcomes associated with the Center for Medicare and Medicaid Innovation (CMMI) expansion of a multi-setting community palliative care program in North and South Carolina.

METHODS: This observational study characterizes the CMMI cohort's care and cost trajectories after enrollment. Program participants were age-eligible Medicare fee for service beneficiaries living in western North Carolina and South Carolina who enrolled in a palliative care program from September 1, 2014 to August 31, 2017. End of life costs were compared between enrolled and non-enrolled decedents. Program administrative data and 100% Medicare claims data was used.

RESULTS: 5,243 Medicare beneficiaries enrolled in the program from community (19%), facility (21%), small hospital (27%) or large hospital (33%) settings. Changes in Medicare expenditures in the 30 days after enrollment varied by setting. Adjusted odds of hospice use were 60% higher (OR= 1.60; CI= 1.47, 1.75) for enrolled decedents relative to non-enrolled decedents. Participants discharged to hospice versus participants not had 17% (OR= 0.83 CI=0.72, 0.94) lower costs. Among enrolled decedents those enrolled for at least 30 days versus <30 days had 42% (OR=0.58, CI=0.49, 0.69) lower costs in the last 30 days of life.

CONCLUSIONS: Expansion of community palliative care programs into multiple enrollment settings is feasible. It may improve hospice utilization among enrollees. Heterogeneous program participation by program setting pose challenges to a standardizing reimbursement policy.