So the buzz is around the office today about new Medicare Part D changes that are going to majorly and adversely affect patients and their families, and also be the death knell for hospices throughout the country.
See the following link for the actual final determination and new rules that are supposed to be effective May 1, 2014:
The Readers' Digest version of this new policy is that patients, once enrolled onto hospice services, will only be covered for medications directly related to the palliation and symptom management of their illness. In example, Sally Jones is admitted to hospice with a Dx: Cervical Cancer. Medicare will now only cover medications directly related to this illness (e.g. Analgesics, Anti-Emetics, Laxatives/Stool Softeners, Anti-Anxiety). But if Sally Jones also suffers from COPD and is also s/p CABG, medications related to those diagnoses will no longer be covered under Medicare Part D and will become the liability of the patient or the hospice provider if they so choose to cover the medications.
So what this means is that hospice patients facing terminal illness for one problem may very well become at greater risk secondary to other comorbidities than their primary diagnosis. Additionally, this will add financial stressors to families already dealing with terminal illness. Coupled with the cuts already hitting hospice providers last year, this is surely going to sink some hospices altogether. And we'e already seeing patients getting their rejection notices for medications two months ahead of this change being implemented.
I'm curious to know thoughts on this. Is this buzzing within your own work culture? Better freshen up those resumes, ladies and gents, because this could be a game changer.
Specializes in NICU, PICU, Transport, L&D, Hospice.
Nice link, baloney. Never would have thought that the top 20 combined don't even count for 25% of the market.
I think that the answer to your question is obvious, however. Yes, there is a difference in business models (simply by your own definition).
I believe the answer is obvious as well but my experience has proven that not all nurses are well enough versed in hospice care to have yet grasped the differences.
Regarding the market share; yes, I thought that was interesting as well. Of course, there are so many very small agencies across the country. I worked for a few years for a larger not for profit with an avg daily census of ~250. They employed a FT marketing staff to maintain and grow that. Still, census would drop, and nurses would be laid off. It is a tough world.
One of those top 10 providers bought a smaller agency and very quickly "took over" a large portion of the SNF hospice care in the area. That made our overall census more acute and consequently more expensive. We practiced in a service area that contained a world class university hospital system as well as a large VA and another 300+ bed catholic hospital. Acutely ill patients with substantial palliative needs who had fewer than 60 days life expectancy were easy to come by. The longer term dementia or elderly CHF patients in SNFs and ALFs became few and far between.
Maybe someone can help me understand what this issue is as someone who isn't all that knowledgeable about the 'business' of hospice.
My understanding is that what CMS has said is that you can't double bill for the same service (which I'm pretty sure was the rule already, they're just reinforcing that). And they haven't actually said you can't bill for medications unrelated to the terminal diagnosis under part D, in fact they provide specific instructions on how to do just that, so what's the issue?
Specializes in NICU, PICU, Transport, L&D, Hospice.
Maybe someone can help me understand what this issue is as someone who isn't all that knowledgeable about the 'business' of hospice.
My understanding is that what CMS has said is that you can't double bill for the same service (which I'm pretty sure was the rule already, they're just reinforcing that). And they haven't actually said you can't bill for medications unrelated to the terminal diagnosis under part D, in fact they provide specific instructions on how to do just that, so what's the issue?
Hospices don't "bill" for medications. All aspects of the hospice plan of care are paid for in the per diem payment to the hospice from either Medicare or other insurance provider. This is why some hospices do not make any attempt to arrange for relationships which would allow for palliative radiation or blood transfusions (for example). Palliative radiation can cost thousands of dollars and may very well exceed the total payment that the hospice would receive for the receiving patient.
I work for a large not-for-profit hospice, and we generally pay for most meds not related to the hospice diagnosis. Meds we regularly exclude are things like insulin and anti-diabetic drugs, BPH meds, stuff like that. But we'll pay for antihypertensives (for example) which the patient has taking for 20 years. I have to admit that I haven't read the new regs carefully (they are long), but I don't see CMS as saying it is going to stop paying for anti-diabetic and BPH drugs for a patient in hospice with cancer or dementia. Is that how other posters are reading it? I know that my hospice is not concerned about compliance with this new reg.
Just this week I had to talk to the Medicare Part D for a patient. I gave the name, dosage and diagnosis for each non-covered med as well as the hospice diagnosis. Once I had done that, the person I talked to processed the meds and faxed the prior-authorizations for each medication. The pharmacy was then able to fill the meds and bill Medicare Part D. I have to do this every 90 days. It is more work, especially since the number I have to call for each patient is different, but it is doable and the patients are able to get the medications they need.
So the buzz is around the office today about new Medicare Part D changes that are going to majorly and adversely affect patients and their families, and also be the death knell for hospices throughout the country.
See the following link for the actual final determination and new rules that are supposed to be effective May 1, 2014:
The Readers' Digest version of this new policy is that patients, once enrolled onto hospice services, will only be covered for medications directly related to the palliation and symptom management of their illness. In example, Sally Jones is admitted to hospice with a Dx: Cervical Cancer. Medicare will now only cover medications directly related to this illness (e.g. Analgesics, Anti-Emetics, Laxatives/Stool Softeners, Anti-Anxiety). But if Sally Jones also suffers from COPD and is also s/p CABG, medications related to those diagnoses will no longer be covered under Medicare Part D and will become the liability of the patient or the hospice provider if they so choose to cover the medications.
So what this means is that hospice patients facing terminal illness for one problem may very well become at greater risk secondary to other comorbidities than their primary diagnosis. Additionally, this will add financial stressors to families already dealing with terminal illness. Coupled with the cuts already hitting hospice providers last year, this is surely going to sink some hospices altogether. And we'e already seeing patients getting their rejection notices for medications two months ahead of this change being implemented.
I'm curious to know thoughts on this. Is this buzzing within your own work culture? Better freshen up those resumes, ladies and gents, because this could be a game changer.
Chordinger
I didn't interpret the article to say Medicare part D will no longer cover unrelated medications.
If I were to believe such is true, then does that also mean Medicare will no longer cover Dr visits or hospitalizations NOT related to the terminal dx? Hmmm....not seeing that happening.. ...
Its not may 1st, but we've had no issues with our pts getting non-related meds covered through their part D.
As far as pts already getting notices about meds not being covered. ....this, in my opinion, is due to obamacare and the individual drug plans. Yes, I've had pts get notices about non-coverage of meds such as cymbalta or ambien, but both of those meds are no longer formulary for the pts part d or secondary insurance. Their non-related meds (dm, htn) continue to be covered.
Specializes in NICU, PICU, Transport, L&D, Hospice.
As far as pts already getting notices about meds not being covered. ....this, in my opinion, is due to obamacare and the individual drug plans. Yes, I've had pts get notices about non-coverage of meds such as cymbalta or ambien, but both of those meds are no longer formulary for the pts part d or secondary insurance. Their non-related meds (dm, htn) continue to be covered.
Are you mixing the regulations for hospice with the general Medicare Prescription Drug Coverage language?
Are you mixing the regulations for hospice with the general Medicare Prescription Drug Coverage language?
Hmmm...what do you mean?
Example: hospice pt with cops dx; comorbidities HTN, DM.
Meds:
-Albuterol (hospice covered)
-Ambien (not hospice formulary, been long term therapy not r/t dx anyway. Medicare part D/supplemental says no longer formulary so won't cover)
-Humalog (non covered thru hospice, Medicare part D pays)
-Roxanol (hospice pays)
-lopressor (Medicare part d/supplemental pays)
-cymbalta (pt has long standing depression, not hospice formulary or covered by hospice, Medicare part D/secondary says no longer on their formulary so not covered)
As far as ambien and cymbalta, they are no longer covered or formulary for Medicare D/supplemental. Of course pt can be switched to an alternative medication which is on their formulary. PCP just needs to approve change.
Did I get it right? This is my understanding.
When pts elect hospice, they don't generally drop their supplemental, as they still need prescription coverage for unrelated meds, as well as unrelated hospitalizations.
Kabin
897 Posts
One of the larger hospice agencies, top 10.