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HOSPICE NEWS NETWORK

Recent News On End-of-Life Care

Volume 17, Number 14 April 9, 2013

A Service of State Hospice Organizations

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MEDPAC CONSIDERS HOSPICE REIMBURSEMENT ISSUES

MedPac commissioners met on April 4. On their agenda was a session on Medicare hospice policy issues. Hospice utilization data from 2011 indicates that more than one-half of patient stays were longer than 180 days. About $2.7 billion dollars were spent on Medicare for patients who had already been served by hospice for longer than a year.

The first and last days of hospice are the most expensive for providers to offer the level of care needed by patients. Specific data, available in the online presentation, was given on the costs of care from admission to day of death. Labor cost data was also given. No data was presented on drugs, CME, supplies, or chaplaincy costs. The data that is available addresses an estimated 68% of hospices’ direct cost.

Given the variances in costs to provide services throughout the hospice stay, an illustration, noted as “preliminary and subject to change,” explored higher payments for the first seven days of care, followed by decreases per day on day eight, day fourteen, and day thirty-one. Payments would then be increased for the seven days before and of death. “Under the illustrative model, payments would increase by more than 2% for the majority of provider-based (70%), nonprofit (61%), and rural (52%) hospices.”

The presentation also addressed the issue of live discharges from hospice. While not all live discharges should be avoided, “high rates of live discharge among some providers may indicate questionable business practices.” In fact, 14% of hospice stays in 2010, or 2.1 millions beneficiaries, ended in live discharge. For-profit hospices are 20% more likely to have live discharges, and above-cap hospices are twice as likely to discharge live patients when compared to hospices below the cap. More data on this issue is in the report as well.

OIG recommended, in 2011, that CMS monitor hospice care in nursing facilities, and that the payment rate to hospice patients in nursing homes be reduced, citing duplicative care by nursing aids in the facility and by hospice. It is not clear why hospices actually provide more nursing aid visits to patients in nursing facilities. “The government should consider 5% Medicare payment cuts for hospice services provided in skilled nursing facilities,” says an article in McKnight’s, “according to Medicare Payment Advisory Commission (MedPAC) commissioners.”

In summary, the presentation recommends: “Medicare spending on long hospice stays is substantial; PPACA medical review provision should be implemented; Initial step on hospice payment reform is possible with current data; Hospices with high live discharge rates warrant monitoring; Payment reduction for hospice care in nursing facilities could be considered. “ (MedPAC, 4/4, http://www.medpac.gov/meeting_search.cfm?SelectedDate=04/04/2013&t=m&month=2013-04; McKnight’s, 4/8, www.mcknights.com/reduce-medicare-payments-for-hospice-care-in-skilled-nursing-facilities-medpac-suggests/article/287722/)

WHAT HOSPICES NEED TO KNOW ABOUT MEDICARE FRAUD AND ABUSE

In an article for NHPCO’s Newsline, Judi Lund Person, BA, MPH, lays out the reasons behind the recent upsurge in federal audits and investigations into fraud and abuse of the Medicare hospice benefit. Lund Person identifies what hospice professionals and board members need to know and do. She begins by explaining the national landscape within which hospices operate, paying special attention to the role of the recently passed Affordable Care Act (ACA), which mandates stricter rules and sentences for those found guilty of fraud and abuse. ACA also provides an additional $350 million over the next ten years to enhance anti-fraud efforts nationwide. Lund Person notes that these efforts are already having a major impact, with nearly $15 billion recovered so far. For more information about the progress of federal anti-fraud regulators, see www.stopmedicarefraud.gov.

Lund Person goes on to identify where hospices are vulnerable in this quickly changing landscape. The Office of the Inspector General (OIG) has identified 28 areas of risk for hospice, all of which are listed in a full-page section of the Newsline article. Patients’ hospice eligibility, and the corresponding documentation to back it up, “remains a top target area for compliance.” Previous history of non-compliance may cause some organizations to come under particularly intense scrutiny. Hospices that are vulnerable in these ways “may require policies and procedures to prevent recurrence.”

Lund Person explains the OIG work plan for this fiscal year, laying out the projects that the OIG will be focusing on in 2013. She concludes with a description of Medicare Administrative Contractors (MACs) and their role in carrying out audits and other requests for documentation from hospice organizations. (Newsline, April 2013)

AT END OF LIFE, COMMUNICATION PROBLEMS PERSIST

Results from a Canadian study on end-of-life communications were published in the April 1 issue of JAMA Internal Medicine. “A lack of discussion about patients’ wishes is often what leads to very aggressive care at the end of life, followed by stress and regret from family members,” says Dr. Daren Heyland of Kingston General Hospital in Ontario. Results emerging from Canada also reflect trends in the United States. “I wish I could tell you that I was surprised [by the results of the Canadian study],” says Dr. R. Sean Morrison, president of the American Academy of Hospice and Palliative Medicine. The study revealed that most patients had talked with their family about their healthcare wishes, but had not talked with their physicians.

To begin to overcome this problem, Dr. Heyland insists that physicians must take responsibility to have these important conversations with their elderly and ill patients, and that patients should be encouraged to express themselves to medical staff. Dr. Morrison emphasizes that the responsibility for these conversations must be put squarely on physicians. “Patients should feel comfortable raising this, but I think that’s a terrible onus to put on patients and families... You shouldn’t be in the position of having to [say], ‘Let me tell you about what I want.’ It should be the doctor asking what the patient wants.” (Reuters, 4/1, www.reuters.com/article/2013/04/01/us-health-end-of-life-talks-idUSBRE9300IO20130401; Philadelphia Inquirer, 4/1, www.philly.com/philly/health/topics/HealthDay675005_20130401_Doctors_Don_t_Ask_About_End-of-Life_Plans__Study_Finds.html; Medscape, 4/1, www.medscape.com/viewarticle/781764; MedPage Today, 4/2, www.medpagetoday.com/Geriatrics/GeneralGeriatrics/38197)

NEW PALLIATIVE CARE GUIDELINES RAISE THE BAR

Newly revised guidelines for palliative care were released during the annual meeting of the American Academy of Hospice and Palliative Medicine. The document encourages the use of discipline-specific certification for every major area of palliative care programs, including chaplaincy.

The palliative care guidelines were last revised in 2009, and since that time the Accreditation Council for Graduate Medical Education “recognized hospice and palliative medicine as a sub-specialty of 11 different parent boards.” This has allowed the development of hospice and palliative medicine fellowships, which are now an eligibility requirement for board certification exams.

In 2011, 46% of deaths in the United States occurred in a hospice care setting, and data suggests that each person who enrolls in hospice reduces overall costs in the last year of life by an average of $2,309. The new guidelines will apply to all hospice and palliative care facilities, regardless of size.

The greatest changes in the guidelines come in areas that are, perhaps, the least easily quantifiable. Betty Ferrell, PhD, RN, notes, “The social, cultural and spiritual domains have undergone the biggest changes in the latest edition.” Under the new guidelines, care providers must make provisions for translation services and cultural competence. They should also give attention to “the spiritual, religious, and existential concerns throughout the illness trajectory.” Because chaplains may only see a small number of the patients in any given care facility, it is especially important that all care providers be equipped to care for the spiritual needs of patients. (Internal Medicine News, 3/22, www.internalmedicinenews.com/specialty-focus/geriatric-medicine/single-article-page/new-palliative-care-guidelines-stress-certification-diversity.html)

HOSPICE NOTES

* NHPCO issued a press release that highlights ten facts about hospice care that the general public should know. “Hospice is about living fully,” says the release, which encourages utilization of hospice care. (PR Newswire, 4/3, www.prnewswire.com/news-releases/ten-facts-about-hospice-care-you-may-not-know-201254121.html)

* Hospices are a “hot” segment for mergers and acquisitions according to Healthcare Finance News. Though acquisitions of traditional Medicare home care businesses have slowed down dramatically, a panel of investment experts said that hospice is still a hot commodity. (Healthcare Finance News, 3/27, www.healthcarefinancenews.com/news/ma-home-care-and-hospice-favors-hospice)

* Caregivers began serving terminally ill inmates in the South Woods State Prison, in New Jersey, in 2002. A recent article highlights the program and the work of the 25 inmates who now serve as caregivers. (TheDailyJoural.com, 3/31, http://www.thedailyjournal.com/apps/pbcs.dll/article?AID=2013304010022&nclick_check=1)

* Most information about palliative care on YouTube is not helpful. Just 28% of videos have useful information on palliative care, hospice and the end of life, according to a study detailed in The Oncology Report. Further, the videos that are of poor quality are watched much more often because they tend to come up earlier in a Google search. (The Oncology Report, 3/28, http://www.oncologypractice.com/oncologyreport/news/top-news/single-view/youtube-poor-source-of-palliative-information/0f389aa553f58b79ad9116f90d935667.html)

PALLIATIVE CARE NOTES

* The Journal of Palliative Medicine highlights the ways that pediatric palliative medicine needs to improve as the field comes to maturity. A recently published article looks at research priorities, pediatric-specific issues, and the broad applications of research in this area. (The Journal of Palliative Medicine, 3/5, online.liebertpub.com/doi/abs/10.1089/jpm.2013.9518?journalCode=jpm)

* A study published in The Journal of Palliative Medicine concludes that palliative sedation is well received by family members because it contributes to a peaceful dying process. Nevertheless, relatives do indicate discontent with how information is provided, and with communication in general. (The Journal of Palliative Medicine, 2013 Apr;16(4);349-55, www.ncbi.nlm.nih.gov/pubmed/23421537)

* An article from New America Media focuses on the practice of Dr. V.J. Periakoil and what she says she has learned from her patients. A leader in palliative care medicine, Dr. Periakoil directs Stanford University’s palliative care fellowship program. (New America Media, 4/3, newamericamedia.org/2013/04/patients-teach-doctor-how-to-heal-at-the-end-of-life.php)

* The California Healthcare Foundation highlights the ways in which palliative care has spread to all of California’s public hospitals. The initiative, Spreading Palliative Care in Public Hospitals, has succeeded in spreading the adoption of palliative medicine across the state. (California Healthcare Foundation, 3/2013, www.chcf.org/publications/2013/03/spreading-palliative-public-hospitals)

POLICY NOTES

* Vermont is considering allowing physician-assisted suicide for those at the end of life. The Vermont Senate recently passed a bill, titled the “Patient Choice and Control at End of Life,” The bill is slated to be considered by the House.” (Martimole Greene, 3/22, bartimolegreene.com/vermont-flirts-with-physician-assisted-end-of-life/)

* Dr. Lachlan Forrow writes for Boston.com about his experience of his own mother’s death, and his reasons for opposing physician-assisted suicide in Massachusetts. He says, “I believe that a moral prerequisite to legalizing ‘assisted suicide’ is ensuring that all patients have reliable access to other basic palliative care options...” (Boston.com, 4/1, www.boston.com/lifestyle/health/mortalmatters/2013/04/haunted_by_a_grandmothers_suffering.html)

* The New York Times asked readers, “Should it be legal for doctors to help end dying patients' lives?” The opinion page published a number of the letters to the editor. (The New York Times, 3/31, www.nytimes.com/2013/03/31/opinion/sunday/sunday-dialogue-choosing-how-we-die.html?_r=1&)

* Connecticut legislators “put aside” the bill dealing with physician-assisted suicide in order to deal with other issues “too vital to risk.” (The Hour, 4/6, http://www.thehour.com/news/state/connecticut-lawmakers-put-aside-assisted-suicide-bill/article_cb148c1e-d984-59a9-bee0-3b08052c724c.html)

Thanks to Don Pendley for contributions.

Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2013. Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division. Ask your insurance agent to visit their website at www.hccis.com.

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