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Medicare reimbursement culture creates biomedical gates’ to care
New report says payment plans are hindering hospice mission
After more than 20 years of Medicare reimbursement for hospice care, the industry has become preoccupied by clinical indicators and local medical review polices that offer guidelines for hospice admission. Too often a prospective hospice patient is defined by clinical indicators, rather than by the psychosocial characteristics that affect the quality of one’s death.
"There has been a shift in intent," says True Ryndes, ANP, MPH, president and chief executive officer of the National Hospice Work Group, and vice president for mission and policy at San Diego Hospice. "What has happened is we’ve created biomedical gates to hospice care."
Local medical review policies suggest certain clinical factors be present for a patient with a specific disease to be admitted to hospice. Yet, it is the non-clinical conditions that hospice workers target once a patient is under their care. In short, the things that drive access to hospice often have very little to do with what hospice is about. The end result can be that access is denied to those who would benefit greatly from hospice care.
A three-year study of hospice access came to a similar conclusion. In April, the Hastings Center and the National Hospice Work Group released their study findings in a report titled Access to Hospice Care: Expanding Boundaries, Overcoming Barriers. The study was published as a special supplement to the March/April 2003 issue of the Hastings Center Journal, a bioethics publication.
The report examines access to and delivery of hospice care from the perspective of social justice, equity, or fairness, and offers recommendations to lawmakers, the hospice industry, and individual hospices.
In the report summary, the authors asked "What is wrong with this picture?" to help drive home the message of the report:
"Maria, a 34-year-old mother of two, received a prenatal diagnosis that her baby has a lethal congenital anomaly and will only briefly live after birth. When Maria’s physician tells her not to schedule more visits until just prior to her due date and sends her home, she reports great emotional distress being left to wait for death’ without any support. A local support group tells her of hospice but the hospice will not accept her until the baby is born alive and lives to go home."
The vignette reveals the conflicting intentions hospices face that ultimately affect whether patients in need of comfort and support are admitted into hospice care. Often, it is patients who progress beyond a hospice’s ability to provide effective care who are admitted simply because they fit a medical criterion.
"Death is an inevitable aspect of the human condition," the report says. "Dying badly is not."
Based upon that premise, the authors offered the following recommendations to improve hospice access and ultimately improve care for the terminally ill:
HMB is a subset of hospice
The authors of the report say the recommendations represent "a course for the future of hospice in America" that requires patience, political leadership, and an openness to new ideas. The recommendations are national in scope, says Ryndes, who was one of four principal authors of the report. Yet, Ryndes acknowledges that individual hospices can take action to help improve hospice access within their own communities.
Improving access from an individual hospice standpoint begins with focusing on individual strengths and resisting the pressure to emphasize biomedical aspects of hospice admission, says Ryndes.
Stephen Connor, vice president for research and development for the National Hospice and Palliative Care Organization in Alexandria, VA, puts it more bluntly: "Hospices cannot let the Hospice Medicare Benefit define hospice care."
The statements of both Ryndes and Connor go against the grain of a hospice reimbursement model rooted in more than two decades of being dependent on Medicare and Medicaid for its collective livelihood. In business terms, too many hospices have a single product line and have catered to only a few well-paying customers. Worse, these customers have allowed hospices to stray from their original mission of treating the dying and their families no matter their circumstances. Medicare’s vigilant efforts to reduce fraud and abuse have conditioned hospices to look at patients from that perspective.
Connor qualifies his statement by saying hospices should not risk alienating these payers by bucking the system. His advice: Make your case for patients you believe should be admitted, even if they fall outside the Medicare guidelines, and look for other ways to pursue the original hospice mission.
The May 7 issue of the Journal of the American Medical Association (JAMA) published a study that suggests other payers are more receptive to hospice. According to the study, Medicare beneficiaries who had been diagnosed with cancer and who were enrolled in managed care plans had consistently higher rates of hospice service and significantly longer hospice stays than those enrolled in fee-for-service plans. The researchers concluded that there is a possibility that managed care plans are more adept at utilizing hospice.
Continue education efforts
For the past several years, hospice experts have debated the kinds of educational efforts that would help improve access. A chicken-or-egg argument has ensued. Should consumer education lead the way? After all, consumers drive the market. Or should physician education lead the way? Physicians do control referrals.
The hospice access report suggests that hospices do both.
Reaching consumers of health care services is a challenge. Convincing consumers that hospice care is an appropriate service at or near the end of life is part education and part trust-building. The hospice access report highlighted three characteristics of hospice valued by consumers:
1. Responses to the human consequences of profound illness (palliative care management).
Hospice staff respond to the need for comfort, safety, choice, and support experienced by dying patients and their families as their conditions change and they move from one care setting to another.
2. Continuity of caregiving.
Hospice staff maintain a coherent vision of what is preferred by and effective for patients and their families as care shifts to new settings and providers.
3. Response to evolving community needs.
Hospice leaders have expanded a philosophy of care originally based on the needs of white, middle-class adults with cancer. Hospices now serve people with many other diseases, as well as children, people living in difficult service areas such as prisons and the rural "outback," and the community’s bereaved.
Another facet of consumer education is engaging the business community (No. 8 on the report’s list of recommendations). "Good care of dying Americans is clearly a workforce issue because it relates to productivity of employees as patients and as caregivers," the authors wrote. "Therefore, the major national hospice foundations, in concert with community hospices, should assist the business community in understanding the economic value associated with support to employees who are caregivers as well as the benefits associated with proactive responses to employees who become chronically ill."
Setting sights for new payer horizons, expansion of services, and education of consumers and physicians to improve access both at the community level and the national level cannot happen unless hospices change their own culture.
Hospices have to take hard looks at themselves and ask if they are still on the charted course of caring for all dying patients. Or are they engaging in behavior that results in admitting patients using narrow criteria to avoid scrutiny?
"Our mission is to take care of dying people, not just those who are motivated for hospice care," says Connor. "We have to reach out to those who don’t know about hospice. Hospices have to find more ways to fulfill their mission. They have to embrace change, including going outside the hospice Medicare benefit."
Medicare reimbursement for hospice increased from $445.5 million in 1991 to $3.6 billion in 2001, a 710% increase. That’s the good news. The bad news is that despite the exponential growth in reimbursement, hospices still have far more of a stake they need to claim in health care spending. Specifically:
If access has not improved — meaning hospices are treating the same types of patients with the same types of disease — yet revenue is increasing, the question hospices must ask themselves is: Whom exactly are we trying to serve?