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Since the inception of the Medicare Hospice Benefit in 1982, hospice has grown into a $10 billion industry that last year alone served more than 1.4 million dying Americans and their family caregivers. The Medicare Hospice Benefit is responsible for millions of people living as fully as possible up until the end of life and the hospice community is dedicated not only to preserving the benefit but enhancing it so it appropriately serves the unique and changing needs of dying Americans. Hospice and palliative care providers, through the support that comes from Medicare, are recognized as the leading providers of the interdisciplinary, holistic care considered to be the gold standard of end-of-life care.
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MedPAC, the congressional advisory committee, has been looking at growth in hospice in recent years which has increased in number of providers and people served. Recommendations from MedPAC involving hospice reimbursement are expected to be released shortly. This consensus statement affirms key issues on which these leadership organizations agree.
Consensus Statement on Hospice Reform
There is broad agreement that the Medicare hospice benefit has been a resounding success. Since its addition to the Medicare system in 1982, tens of millions of patients and families have availed themselves of its unique, interdisciplinary and cost effective approach to end of life care. Moreover, patient and family satisfaction with this high quality health care delivery system is extremely high. Quoting from a recent independent economic study from Duke University, clearly demonstrating the cost effectiveness of the Medicare hospice benefit, "...the Medicare program appears to have the rare situation whereby something that improves quality of life also appears to reduce costs."
Each year, a growing number of patients and families are accessing hospice care when they or their loved ones are facing the end of life. Health care professionals, as well as the public, are increasingly recognizing the value of this health care delivery system. Based upon demonstrated patient and family satisfaction with the care, the cost savings involved and the inherent compassionate philosophy of care that serves as a foundation for hospice, this growth has been encouraged by consumers and policymakers alike. Indeed, sound policy should foster growth in the Medicare hospice benefit.
Since 1982, patient demographics, treatment protocols, and public attitudes about healthcare have changed and the Medicare hospice benefit needs to keep pace with these dynamics in order to serve an ever larger, and more diverse, portion of our dying population and their families.
Payment policy is one of the areas that needs to stay current so that payment appropriately recognizes changes in patient demographics and treatment protocols. Updates should be carefully considered and evidence based to ensure that behavioral consequences are understood prior to implementation. The present payment methodology has served the hospice community and the public well since its inception, virtually without change. Analysis of both current and historical patient level data is necessary to fully understand and predict future behavior and needs, and make changes that continue to provide benefits to patients and to the Medicare system.
As with any payment system, dramatic changes to the hospice benefit from established patterns of reimbursement are sure to produce displacements and unintended negative consequences. Given the nature of hospice referrals and the unique characteristics of the end of life patient demographics, unintended consequences of such changes are inherently difficult to predict. Any number of issues might warrant attention, but effectively quantifying such items in terms of behavior changes of patients and providers would be difficult. Payment reforms should be incremental, based on adequate data analysis, and need to be undertaken carefully, with effects on the patient and family in mind.
Over the past several years, MedPAC has undertaken a review of the Medicare hospice benefit. While specific reforms and enhanced accountability measures are laudable and should be encouraged, those changes should be framed in the context of a comprehensive review of the various and complex components of end of life care and how the continuum of care can be expanded to increase access for patients and families. Included in this comprehensive review of hospice should be payment methodologies, fiscal constraints review, alternative eligibility criteria, and testing of new models of care, as well as any number of other issues. The hospice community is committed to work toward these goals.
Guiding this review ought to be several clear principles. Among them are:
Responses to draft MedPAC Recommendations, dated 11/6/08:
Recommendation #1: The Congress should change the current Medicare payment system for hospice to reduce payments per day as the length of the episode increases. The revised payment system should include a payment adjustment to reflect hospices' higher costs associated with patient death at the end of the episode.
A payment system that more closely matches or "tracks" actual cost curves of patient care, such as a "first and last periods of care" system, done on a budget neutral basis, has merit. There are key issues in developing such a design that need to be substantiated and tested against comprehensive and broad-based data. Only after such data is collected, analyzed, and understood, can it serve as the basis for rational and appropriate payment reform.
Recommendation #2a: The Congress should direct the Secretary to:
Certain additional safeguards might be put into place given changing patient demographics and, in some isolated instances, very long lengths of stay for patient. Included in this area is the need for a hospice physician or advanced practice nurse to personally visit the patient to determine continued eligibility after receiving hospice care for 180 days and, at each subsequent recertification and to attest that such visits took place. In addition, re-certifications should include a brief narrative describing the clinical basis for the patient's terminal prognosis. With regard to hospices with very long lengths of stay, fiscal intermediaries already have existing responsibility to monitor patients' continuing eligibility. Special consideration should be given to the unique issues facing rural and small hospice providers in assessing the impact and implementation of such measures.
Recommendation #2b: The Secretary should direct the OIG to investigate the prevalence of financial relationships between hospices and nursing facilities that may represent a conflict of interest and influence admissions to hospice, differences in patterns of nursing home referrals to hospice, and the appropriateness of hospice marketing materials. The Secretary should make this information available through data use agreements.
With increased utilization of hospice care and growth in the number of providers, it is prudent to encourage appropriate local, state and federal government entities to review financial and contractual relationships between hospice and other health care facilities that may give the appearance of a conflict of interest and potentially influence referrals to hospice. If any instances of fraud and abuse are discovered, they should be immediately reported to the appropriate authorities. In addition, appropriate resources should be directed to undertake more timely and regular surveys of hospice programs, at least as frequently as every three years. Such surveys should be undertaken by highly trained and competent governmental professionals using the recently revised conditions of participation in mind.
Recommendation #3: As a condition of payment, the Secretary should require that hospices report information on all visits provided to the hospice patient on hospice claims, including length of visit.
In order to facilitate better and more complete data collection, hospices should report comprehensive information on patient visits (including telephonic contacts) on hospice claim forms, including length of visits or interactions. This enhanced and comprehensive data collection should be collected and compiled with a clear and stated purpose in mind.
Recommendation #4: The Secretary should change cost reports to reflect new data on hospice claims, add new data fields to capture the full range of hospice revenues in order to provide a more accurate picture of hospices' financial performance, and increase the accuracy of cost report data through audits or other processes so that these data can be used in setting, adjusting, or rebasing payments, as warranted.
Hospice cost reports should be changed, to better reflect new data on hospice claims, adding new data fields to capture the full range of hospice revenues in order to provide a more accurate picture of hospices' financial performance. These changes would increase the accuracy of cost report data through audits or other processes so that these data can be used more reliably in analyzing hospice payment issues. Such an effort should be undertaken with hospice community input and cooperation.
The shared mission of all hospice providers, to bring compassionate, high-quality care to appropriately eligible patients and families coping with life-limiting illness continues to resonate strongly at the heart of the hospice community. As we as a nation move forward, facing the growing health care needs and demands of our diverse population, hospice is committed to serving the most vulnerable of our population, the dying.
Editor's Note: Representatives of the organizations releasing this statement are available for comment.
-- Advancing hospice and palliative care providers as the recognized providers of end of life care. -- Preserving and enhancing the Medicare Hospice Benefit. -- Recognizing high quality as the standard to which all providers must subscribe. -- Ensuring accountability through transparency and fair regulatory scrutiny. -- Promoting increased access through expansion and collaboration.
SOURCE National Hospice and Palliative Care Organization
