Medicare Care Choices Model Improved End-Of-Life Care, Lowered Medicare Expenditures, And Increased Hospice Use

The Medicare Care Choices Model (MCCM) tested a new option for eligible Medicare beneficiaries to receive conventional treatment for terminal conditions along with supportive and palliative care from participating hospice providers. Using claims data, we estimated differences in average outcomes from enrollment to death between deceased MCCM enrollees and matched comparison beneficiaries who received usual services covered by original Medicare. Enrollees were 15 percentage points less likely to receive an aggressive life-prolonging treatment at the end of life and spent more than five more days at home. MCCM also reduced net Medicare expenditures by 13 percent, decreased inpatient admissions by 26 percent, reduced outpatient emergency department visits by 12 percent, and increased hospice use by 18 percentage points. Although the Centers for Medicare and Medicaid Services did not expand the model, given concerns about generalizability, these results provide evidence that MCCM is a promising approach to transforming care delivery at the end of life.

Hidden Costs Associated with Conversion from Peritoneal Dialysis to Hemodialysis

Background

Increasing use of peritoneal dialysis (PD) will likely lead to increasing numbers of patients transitioning from PD to hemodialysis (HD). We describe the characteristics of patients who discontinued PD and converted to HD, trajectories of acute-care encounter rates and the total cost of care both before and after PD discontinuation, and the incidence of modality-related outcomes after PD discontinuation.

Methods

We analyzed data in the United States Renal Data System to identify patients aged ≥12 years who were newly diagnosed with ESKD in 2001-2017, initiated PD during the first year of ESKD, and discontinued PD in 2009-2018. We estimated monthly rates of hospital admissions, observation stays, emergency department encounters, and Medicare Parts A and B costs during the 12 months before and after conversion from PD to HD, and the incidence of home HD initiation, death, and kidney transplantation after conversion to in-facility HD.

Results

Among 232,699 patients who initiated PD, there were 124,213 patients who discontinued PD. Among them, 68,743 (55%) converted to HD. In this subgroup, monthly rates of acute-care encounters and total costs of care to Medicare sharply increased during the 6 months preceding PD discontinuation, peaking at 96.2 acute-care encounters per 100 patient-months and $20,701 per patient in the last month of PD. After conversion, rates decreased, but remained higher than before conversion. Among patients who converted to in-facility HD, the cumulative incidence of home HD initiation, death, and kidney transplantation at 24 months was 3%, 25%, and 7%, respectively.

Conclusions

The transition from PD to HD is characterized by high rates of acute-care encounters and health-care expenditures. Quality improvement efforts should be aimed at improving transitions and encouraging both home HD and kidney transplantation after PD discontinuation.