Redesign Medicare Hospice Benefit – the goal of the study is to provide a rational, patient-defined, evidence-based recommendation to inform the redesign of the Medicare hospice benefit, transitioning policy from the current hospice benefit to a more  patient-centered palliative care model.

We are developing and will utilize a Choosing Healthplans All Together (CHAT) tool for use with DUHS cancer patients.  Eligible patients will be 65 years of age or older and Medicare eligible (and their family member caregivers) who have cancer and have received anti-cancer therapy within the last 12 months, or have metastatic cancer regardless of time period of last treatment.  Equal numbers of patients (n = 300) and family member/caregivers (n = 300) will be enrolled so as to ascertain patient and family preferences about the types of care that should be provided to patients near the end of life.

Description of CHAT process: Patients and caregivers participate in structured simulation exercises designed to allow laypersons to construct health plans within the constraint of limited resources. A version of the CHAT exercise specifically based on Medicare services at the end of life has been developed for use in this study.

The first step of the exercise uses a circular game board in which benefit categories are represented. Participants select their Medicare insurance package by distributing stickers among the holes on the board. Participants can select Basic, Intermediate, or High options for each benefit category or may forgo a category altogether, thus offering the possibility of numerous variations in the health plan design. A participant’s manual describes the features of each of the benefit categories and their associated options.

During the exercise, selection occurs four times to allow participants to make choices and face consequences: (a) alone, (b) in groups of three, (c) as an entire group, and (d) once again alone.  Players receive event cards following the first two cycles of benefit selection.  The health event cards describe illness scenarios and the associated consequences of coverage choices.  For example, if a participant does not choose to cover any level of home health care and then picks the home health care health event card, the consequence will be that family and friends will have to provide all such help needed.

The sequence of repeated decision cycles is intended to promote group decision making, including discussion and deliberation about what participants consider valuable and why. Repeated cycles also allow comparison of individual and group choices.  Pre- and post-exercise questionnaires will be administered.

Benefit categories are broken down as follows: Advice, Cancer Care, Cash, Complementary, Cosmetic, Dental/Vision, Drugs, Emotional Supports, Home care, Home Improvements, House Calls, Nursing Facility, Other Medical Care, Palliative Care, and Primary Care.

Participants are allowed to allocate benefit levels and categories based on a global budget that reflects the cost of care during the last 180 days of life.  Medicare 5% cost sample cost data were used to determine the global budget as well as the costs per category and for levels of care within a category.

  • Will the preferences of patients or family members change over time as a result of participating in the CHAT exercise?
  • Do care preferences differ based on race?
  • Do the preferences of patients differ from those of family members?
  • Do the preferences of terminally ill cancer patients differ from preferences of the general Medicare population?

The overarching goal of the project is to reconsider how Medicare finances end-of-life care, and to frame the reconsideration and base any proposed benefit changes around the preferences of patients with advanced cancer and their family members.  A key task in doing so is to analyze the data collected in the CHAT exercises, and therefore, document the care preferences of patients and family members near the end of life.  The documented preferences will be used to develop the palliative care benefit for the Medicare program that we will propose.   Study staff will simulate the cost impact of this benefit on Medicare as compared to the cost impact of the existing hospice benefit.  We will also distinguish the cost impact on the Medicare program from impact on patients and families.

  • Funder: Agency for Healthcare Research and Quality (AHRQ), U.S. Dept. of Health & Human Services
  • Grant #: 1R01HS018360-01
  • Effective dates: September 1, 2009-November 30, 2012