• Evaluate high rates of hospital transfer as evidence of potentially avoidable adverse events.

  • Modify home care eligibility to ease the homebound requirement.

  • Ensure quick availability of key consultations for difficult symptoms arising in a home care patient.

  • Establish rate and enrollment criteria encouraging “bridge programs” that are integrated with hospice.

  • Try out integrated home-hospice-institutional care programs (PACE, MediCaring).

  • Encourage geographic concentration by programs.

  • In PACE, the payment rate for Medicare is set at the nursing home rate and Medicaid makes up the rest. The Medicare rate is almost certainly too low for cancer patients, forcing Medicaid to make up more of the overall rate and thereby making PACE care of cancer patients unattractive for the states. PACE’s Medicare payments could mirror the risk adjustment rates, once those are set.

  • Make risk adjustment plans cover end-of-life care (e.g., for patients not likely to live into next year; for patients cared for mainly out of hospital).

  • Purchase on quality of end-of-life care.

  • Adjust the risk adjustment plan to improve end-of-life care.

  • Reduce the differential between procedure and counseling payments.

  • Designate palliative care specialization, to avoid problems with concurrent care.

  • Provide incentives for advance planning before repeat hospitalization.

  • Provide incentives for coordinated care before repeat hospitalizations.

  • Provide incentives for services in centers of proven quality in end-of-life care.

  • Pay family caregivers a discounted rate for their services (e.g., half the going rate for paid services).

  • Provide health insurance for full-time family caregivers who have no other source of insurance.

  • Provide payment for respite help, either in-home or in-facility.

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