The Death Knell Of Hospices Everywhere

toomuchbaloney · Mar 18, 2014

"For prescription drugs to be covered under Part D when the enrollee has elected hospice, the

drug must be for treatment of a condition that is completely unrelated to the terminal illness

or related conditions; in other words, the drug is unrelated to the terminal prognosis of the individual.

We expect drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances."

The Hospice patient with a cancer diagnosis will continue with appropriate payment for pre-existing medications for CHD, COPD, etc.

It is important that hospices discontinue what has previously been very sloppy standards of care for the election of benefit documentation and medication review. Too many hospices were not providing the level of oversight, planning, and intervention that are necessary under the law.

Too many hospice clinicians do not appreciate the importance of correctly identifying the admitting diagnosis and the related/covered medications versus the unrelated/uncovered medications. Too many nurses have essentially "skipped" over that time consuming and frustrating task of completing an exhaustive review of the medication POC at the time of election of benefit. The verbal review with the physician is too often a cursory phone call that covers little in way of medication appropriateness. Too often hospice teams have little to no input from a qualified pharmacist who engages in questioning the appropriateness of medications as related to the terminal diagnosis.

Yes, this will be challenging for many hospices. It is important that rules are followed, however, if we don't want finite monetary resources misspent.IMHO

chordringer · Mar 18, 2014

What is said, is not what's being practiced. We already have 3 patients who have received these notices and their medications, which we already were not covering, were being denied coverage through Medicare part D. The verbiage in these notices point the finger at the hospices, but that doesn't jive. Families are getting very upset and may decide to revoke altogether.

elkpark · Mar 18, 2014

I've worked as a surveyor/regulator for my state and CMS in the past, and, in my experience, these kinds of rule changes are always reactive, not proactive. In other words, they are usually implemented as a response to some widespread, longstanding problem, which I suspect, in this situation, is likely inappropriate/excessive charges (or, at least, sloppy work) by too many hospices around the country.

I would expect that it is not a "death knell" for hospices so much as a "wake-up call." Hospices that are committed to providing people appropriate services will manage to continue to serve families within the new guidelines and requirements. Hospices that are primarily looking to maximize revenues/incomes will be in some trouble.

toomuchbaloney · Mar 18, 2014

What is said, is not what's being practiced. We already have 3 patients who have received these notices and their medications, which we already were not covering, were being denied coverage through Medicare part D. The verbiage in these notices point the finger at the hospices, but that doesn't jive. Families are getting very upset and may decide to revoke altogether.

The suggestion then is that your hospice was excluding medications which ARE/WERE related in some fashion to the terminal diagnosis. These exclusions are one of the ways that for-profit hospice agencies reduce costs in order to create profit, they INTENTIONALLY create very narrow and small medication POCs with the goal of containing costs. Typically, medications represent the highest costs in the hospice world outside of salaries.

Additionally, such exclusions can be the result of lazy or sloppy work where the nuanced connection between two medical conditions (depression and the terminal diagnosis as an obvious example) are not explored and identified.

It is difficult for some small hospices to provide care for some patients requiring expensive treatment as part of their palliative POC. Some of those smaller agencies decline to admit patients with complicated and expensive medication plans, who require palliative radiation, or palliative transfusions simply because they cannot afford the care.

http://www.medpac.gov/publications%5Ccongressional_reports%5CJune04_ch6.pdf

Hospices falling below the median for average daily census or total annual admissions may have a more difficult time affording those patients with expensive palliative needs. Where does your agency fall in that spectrum? http://www.nhpco.org/sites/default/files/public/Statistics_Research/2013_Facts_Figures.pdf

elkpark makes an excellent distinction here about the nature of CMS rules; reactive rather than proactive. If one sees a new rule from CMS look behind it to find a problem requiring a remedy.

Kabin · Mar 20, 2014

It will get ugly for many hospice agencies very quickly. Hospice conditions of participation are pretty clear that hospice agencies can't cherry-pick patients. The patient is either hospice appropriate or not. Cost isn't an admission criteria.

We've always done well covering meds and DME related to the hospice diagnosis but covering meds and DME related to second and third potentially terminal diagnoses will be daunting. And from what we're hearing Medicare has no plans to increase reimbursement rates. I'd guess that'll have to change within a year.

toomuchbaloney · Mar 20, 2014

It will get ugly for many hospice agencies very quickly. Hospice conditions of participation are pretty clear that hospice agencies can't cherry-pick patients. The patient is either hospice appropriate or not. Cost isn't an admission criteria.
We've always done well covering meds and DME related to the hospice diagnosis but covering meds and DME related to second and third potentially terminal diagnoses will be daunting. And from what we're hearing Medicare has no plans to increase reimbursement rates. I'd guess that'll have to change within a year.

Bold mine.

Reread the rule.

They are not suggesting that the medications or DME for an unrelated potentially terminal Dx be covered, only that all medications and DME related to the admitting terminal diagnosis (and related conditions) be covered.

So many of the chronic disease states are interrelated it can be difficult to separate them, right?

For instance, the little old lady with COPD will likely have some alterations in cardiac function, right? She may have evidence acute or chronic renal failure as well as back pain. Similarly the patient with Heart failure will likely have some alterations in renal function. Our job is to sort through these things, discover what came first, where are the cause and effect relationships, and then act according to our best professional judgement as a team. I have participated in some lively discussions between the MD, PharmD, and RN relative to the medication POC of the patient. In my view, that is necessary to insure that we are treating the patient according to the CoPs and not just considering the bottom line of the agency.

If your agency is in the habit of admitting patients with "Debility" or similar diagnosis the medication nuances can be nightmarish.

Perhaps your agency does admit every patient who meets the clinical criteria. Some do not and will refer to a larger agency because they are unable to meet the needs of the patient (also a requirement of the CoPs). So, for instance, if your agency cannot meet the need for serial transfusions or palliative radiation because you do not have those relationships and contracts in place it is acceptable to refer the patient to another hospice provider which can meet that need. If the patient requires daily volunteer assistance and your agency does not have that capacity it is acceptable to refer them to another agency which can meet that need. Can you see how that works?

Hospice today is a very competitive field and there have been some sloppy and sometimes unethical practices noted by those who care and pay attention.

Agreed that the reimbursement for Hospice is unnecessarily low and should be reviewed. My guess, however, is that it won't be increased as the mood of our Congress is not in favor of assisting the poor and middle class citizens with health care, nutrition, or unemployment needs. Of course, the wealthy can afford whatever care they prefer.

Kabin · Mar 20, 2014

As with many, we've been covering everything related to the primary term diagnosis for years and now just beginning to do the ground work in prep for covering any related illness. We're being instructed to look for at least 2 related illnesses to the primary terminal diagnosis. There's no way around it, it'll get expensive quick. We're being told the government's ultimate goal is to bundle all end of life costs.

toomuchbaloney · Mar 20, 2014

"Bundled care" is a pretty good description of the essence of Hospice billing in the USA today.

That approach has proven to be more cost effective than the fee for service model, particularly when applied to palliative rather than curative care.

Having said that, bundled billing (or episode based payment) is not a new phenomenon in health care and has been found to reduce unnecessary services and reduce cost without diminishing outcomes (which are already not that great in the USA, comparatively). An example of health care which may be bundled is Maternity care including delivery. There have been some pretty good studies on bundling CABG and arthroscopic interventions, for instance.

Our current health care delivery system is pretty fragmented and that makes transitioning to this form of payment more difficult when the typical patient experience is divided between a variety of providers (surgeons, oncologists, radiologists, etc) and care environments (office, hospital, rehab, home, etc). The effective plan requires more coordination and collaboration than many providers are accustomed to or have the structure in place to provide. Nurse case managers are invaluable to those coordination and cost saving efforts, by the way.

One can only imagine how testy some discussions might be when it comes time to divide the single payment between different providers.

I hope you are finding this an enjoyable discussion, I am.

Kabin · Mar 20, 2014

Hospice bundling in the past was only around the terminal diagnosis and included many caveats. Soon it will be bundling coexisting and additional diagnoses related to the term condition or related conditions worsening the terminal prognosis. Hospice agency cost burden will increase substantially. Soon enough it's gonna suck to be us. :)

Kabin · Mar 20, 2014

In times like this it's probably best to be involved with hands on clinical. Try to avoid fluff programs, overhead assignments, and middle management jobs.

toomuchbaloney · Mar 21, 2014

I wonder, Kabin, do you work for a not for profit or a for profit hospice agency?

Is it hospital associated or stand alone?

How big is it?

Just curious.