The National Hospice and Palliative Care Organization offers some additional thoughts that are helpful in understanding hospice care provision in the U.S., prompted by the article in today’s Wall Street Journal by journalists Christopher Weaver, Anna Wilde Mathews, and Tom McGinty. (WSJ articles are available online only by subscription.)
The Medicare hospice benefit was designed in 1982 to be the first “managed care” program within Medicare. A flat per diem payment was envisioned, to provide a pool of funds for the hospice program to manage virtually ALL of the patient’s and family’s terminal illness needs.
While designed initially for cancer patients, the Medicare hospice benefit has the flexibility to adapt to changing patient demographics, with hospices caring for a full range of terminal patients and their families. Now, cancer accounts for just over 36 percent of patient diagnoses. With Alzheimer’s and dementia leading the list of non-cancer diagnoses, the hospice patient of today can be far more complex than only a decade ago. It is NHPCO’s belief that the overwhelming majority of hospice programs are striving to be fully compliant while offering a high quality of end-of-life care.
Accounting for long-stay patients is an issue that has drawn both media and regulatory attention and attempts to understand length of service are understandable.
However, the Wall Street Journal article ignores the fact that fully one-third of hospice patients die within seven days, and almost two-thirds of patients die within 30 days. From a financial standpoint, the longer stay patients, assuming they meet eligibility requirements, are the “balance” against the higher cost short stay patients.
And in fact, short stay patients and their families are denied the benefit of the full range of hospice services; what is intended to be compassionate care often evolves into crisis care.
NHPCO has been a long-term advocate calling for increased transparency, program integrity, and accountability and cites the passage of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 as an important advancement for the field that brings more timely and appropriate oversight. A provision requiring CMS to conduct a medical review of providers with patient stays longer than 180 days is an additional safeguard that is still new to the provider community and one we have supported.
The hospice community also supports the newly enacted payment reform that went into effect on January 1, 2016. It pays a higher per diem rate for the first 60 days of care and a lower rate for subsequent days. In addition, the new payment rates provide for reimbursement of additional clinical visits in the last seven days of life.
Additionally, the Centers for Medicare and Medicaid Services has instituted the “face-to-face” rule, requiring physicians to conduct face-to-face visits for recertification of patients who have been under care 180 days and for who continued hospice care is required.
While these measures will not address every outlier of concern, they are important provisions to increase compliance.
NHPCO has consistently stressed that compliance and quality are not optional. If hospice programs are abusing the system, then they ought to be singled-out and their practices corrected.
“Improper admissions or practices by any provider should not be tolerated. Period. That said, care of the dying can be a difficult issue to understand. The journey that every human being takes at the end of life is unique to that person – it cannot be predicted with complete certainty,” said J. Donald Schumacher, president and CEO of NHPCO.
“Research into the provision of end-of-life care is critically important but we must never forget to factor in the myriad of issues that makes a death different from any other. Ultimately, providing the highest quality care possible to dying Americans, which at times can be hard to quantify, must always be at the foundation of a discussion of hospice,” stressed Schumacher.
Hospice care is patient/caregiver/family-directed care with a plan of care unique to each patient delivered by an interdisciplinary team of professionals that includes nurses, social workers, physicians, allied therapists, home health aides, chaplains, bereavement counselors, and trained volunteers. Hospice cares for the “whole” person focusing not only on the physical needs of the patient but also the psychosocial and spiritual needs as well and bereavement services are provided to family caregivers.
NHPCO offers some additional Key Messages about hospice along with this statement on the organization’s website.