Help! What meds are not covered under hospice?

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Specializes in hospice, Med-Surgical, Cardio-Pulmonary.

Our hospice has been advised that we may be paying for "unnecessary" meds that shouldn't be covered under the hospice benefit. We have always paid for medications related to the terminal illness and meds for symptom management. Our pharmacy bills are very high. We would like some insight on what meds we really shouldn't be paying for.

Do we limit meds that are are only going to provide relief for symptoms that are directly caused by the terminal illness? What about meds for insomnia?, anxiety? confusion? edema? indigestion?terminal restlessness?

I have always thought that we provide "comfort" meds.

Also, I would like to know how many hospice provides "emergency meds" or "care packages" upon admission that may include Roxanol, ativan and atropine for terminal congestion. If you don't place these in the home upon admission, how do you handle it? Do you wait for the patient to become dysphaic, congested and restless before placing it in the home? We like to have a few meds on hand to provide rapid relief (avoiding waiting to get the meds filled and delivered). All suggestions are appreciated!

Thank you. Thank you!

:heartbeat

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any meds r/t the terminal illness, should be covered.

any meds not r/t the terminal illness (bp, thyroid, insulin, etc) wouldn't be covered.

sometimes the md has to fill out a form of medical necessity, explaining why the hospice pt needs a certain med.

but this does not happen often.

leslie

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Many times our medical director will ask that a cheaper med be ordered in place of a more expensive one. Our pharmacy has a formulary which we try to go by but exceptions are made. As Leslie said, if it's r/t the hospice diagnosis, it should be covered. Hospices do not have to cover OTC meds, though many do (we don't and have saved quite a bit on that.) Can you give some examples of what meds you all are considering not paying for?

Our hospice uses e-kits on most admissions - but most of our nurses know to prepare by getting meds in the home in advance - ie: if you have a patient that has COPD - go ahead and order them some roxanol and ativan even if they are not using it right now.

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Specializes in Med Surg, Administration, ER, OR, SCU,.

We cover all meds related to the terminal illness for comfort/ pain control. I would love to have the e-packs, but we don't use them. To me, that would save a lot of $$ in that you'd only have a few of each e-med on hand instead of having to get scripts for all of the different ones and having the pharmacy fill a 15 day supply. I absolutely hate having to throw those meds away when a patient dies within a few days of admission - especially the Duragesic patches, but that's our policy so that's what I do. Once we had a patient on 300 mcg/hr and I had to throw away 3 full boxes!! :o Ouch... that hurt.

We had a very interesting report generated by our med payor ( Procare ). They did an analysis of what meds were currently used versus what would be recommended and the costs of each plus the amount we'd save by using the less expensive meds. I try to do that anyway, but sometimes the MD's order expensive meds without a clue as to how much they cost!

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this is where a med'l dir is worth his/her wt in gold.

one who has an extensive background in hospice/palliative care, will know the ins and outs of the medications, generic vs name brand, labeled and unlabeled uses, etc.

i've worked with med'l directors who literally could make a pts' life, a living and dying nightmare, all r/t inexperience.

when you have one who's a true pro, you do everything to ensure s/he's happy.

leslie

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Specializes in Hospice, OR, Home Health, Orthopedics.
Our hospice has been advised that we may be paying for "unnecessary" meds that shouldn't be covered under the hospice benefit. We have always paid for medications related to the terminal illness and meds for symptom management. Our pharmacy bills are very high. We would like some insight on what meds we really shouldn't be paying for.

Do we limit meds that are are only going to provide relief for symptoms that are directly caused by the terminal illness? What about meds for insomnia?, anxiety? confusion? edema? indigestion?terminal restlessness?

I have always thought that we provide "comfort" meds.

Also, I would like to know how many hospice provides "emergency meds" or "care packages" upon admission that may include Roxanol, ativan and atropine for terminal congestion. If you don't place these in the home upon admission, how do you handle it? Do you wait for the patient to become dysphaic, congested and restless before placing it in the home? We like to have a few meds on hand to provide rapid relief (avoiding waiting to get the meds filled and delivered). All suggestions are appreciated!

Thank you. Thank you!

:heartbeat

As the other nurses have also answered, the meds covered should be the ones that related to the terminal diagnosis, but even then we differentiate. Ex: patient with end stage CHF. Has Lasix, Dig, K+, and Morphine. We cover the Lasix, K+, and Morphine. Not the digoxin, it's treatment. We cover all meds related to symptoms. We work with a pharmacy called Hospce Pharmacia, and they have a formulary which they have nicknamed MUGS (medication use guidelines). If we don't step outside of MUGS, we do pretty well on our medication bills.

Has your hospice tried a formulary or a contract pharmacy?

We also have a comfort pak that we place in the home, and if we order one on each patient the pharmacy gives us a discount (because in the long run, it's gonna save both of us money because we wont' be ordering things in a hurry, getting some locally, ordering extra meds at the end of the week....etc.

I don't know if this helped?? :uhoh3:

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Specializes in Oncology/Haemetology/HIV.

It depends on the Hospice/insurance involved. There is no hard and fast National rule that I know of.

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It depends on the Hospice/insurance involved. There is no hard and fast National rule that I know of.

Actually I believe that medicare regs require the hospice to pay for meds that are r/t to the hospice diagnosis. Some private insurances continue to pay for medications but most of the time the ones that are r/t the hospice diagnosis are supposed to be covered by the hospice and many times the insurance will refuse to pay for them after a patient has been put on hospice.

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As the other nurses have also answered, the meds covered should be the ones that related to the terminal diagnosis, but even then we differentiate. Ex: patient with end stage CHF. Has Lasix, Dig, K+, and Morphine. We cover the Lasix, K+, and Morphine. Not the digoxin, it's treatment. We cover all meds related to symptoms. We work with a pharmacy called Hospce Pharmacia, and they have a formulary which they have nicknamed MUGS (medication use guidelines). If we don't step outside of MUGS, we do pretty well on our medication bills.

Has your hospice tried a formulary or a contract pharmacy?

We also have a comfort pak that we place in the home, and if we order one on each patient the pharmacy gives us a discount (because in the long run, it's gonna save both of us money because we wont' be ordering things in a hurry, getting some locally, ordering extra meds at the end of the week....etc.

I don't know if this helped?? :uhoh3:

I would argue that the digoxin is r/t to the hospice diagnosis and should be paid for. Just a side note, we recently were turned down payment for a diagnosis of CHF because it is a symptom, not the disease. We have now stopped using CHF and always use "end stage heart."

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Yes, our hospice would cover the digoxin also. With end stage heart, the meds to make comfortable are at the same time considered treatment. I'm ok with that, we have to keep folks comfy.

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Specializes in Hospice and Palliative Care.

Yes, any medication that is related to the "comfort" of the patient would be a hospice covered medication. We started partnering with Hospice Pharmacia (www.hospicepharmacia.com) about 3 years ago. They are a research based (EBP) organization and have developed algorythms for each terminal process and which medications would be covered....or not! They also provide Comfort Paks, which are a god-send. Upon each admission, our nurse takes a Comfort Pak with her....the pak has a 4 day supply of Roxanol, Ativan, Haldol, Compazine PO & PR, Acetaminophen PR, ABHR PR (Ativan, Benadryl, Haldol, Reglan compounded into a suppository) and Levsin. They also provide, upon order Cardiac Paks and Seizure Paks. Our pharmacy bills have decreased by about 30% as Hospice Pharmacia bills us on a per diem basis for each patient on census. The best part is they have helped to standardize our practice between our 3 branch offices and our in-patient residence.

They are wonderful....trained, end-of-life pharmacists available 24/7 for consultation. I have never had a situation where they were not more than helpful and knowledgable....and, our census runs almost 300 patients on any given day!

Good Luck & check out HP's website....they will also provide a informational packet and visit if you are serious about partnering with them!

KittyLoverRN in Michigan

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As the other nurses have also answered, the meds covered should be the ones that related to the terminal diagnosis, but even then we differentiate. Ex: patient with end stage CHF. Has Lasix, Dig, K+, and Morphine. We cover the Lasix, K+, and Morphine. Not the digoxin, it's treatment. We cover all meds related to symptoms. We work with a pharmacy called Hospce Pharmacia, and they have a formulary which they have nicknamed MUGS (medication use guidelines). :

Are you sure you don't cover the digoxin? It's in the MUG as covered for Heart related diagnosis. See page 107 in the Seventh Edition.

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