Reimbursing Doctors For End Of Life Discussions

Reimbursing Doctors For End Of Life Discussions

Posted on Monday, September 8th, 2014 at 8:47 am by lifemediamatters

Medicare could soon begin reimbursing physicians for end of life conversations with patients, almost five years after similar proposals were taken out of the Affordable Care Act.

Bypassing the political process, some private insurers have already started reimbursing doctors for time spent helping patients complete advance health care directives, The New York Times reports. Interest in doctor-patient communication has risen as the millions of baby boomers age.

Sessions for some 50 million other Americans could be covered by Medicare if recent requests from the American Medical Association, the nation’s largest association of physicians and medical students, are approved. The AMA recently created codes for end of life conversations and submitted them to the Centers for Medicare and Medicaid Services (CMS).

“Each year, the AMA provides CMS with revisions to the CPT (Current Procedural Terminology) coding system that is used to price thousands of physician services. In a typical year, there are hundreds of codes that are either new, revised or deleted,” according to a CMS statement sent to Life Matters Media. “Advanced care planning was among the codes sent to us by the AMA.”

CMS may choose to establish payment and cover the sessions as described by the code; not pay for the specific code, but cover the sessions as part of another code; or deny payment. A decision is expected this fall.

“We think it’s really important to incentivize this kind of care,” Dr. Barbara Levy, chair of the AMA committee that sends codes to CMS, told the Times. “The idea is to make sure patients and their families understand the consequences, the pros and cons and options so they can make the best decision for them.”

The signature of President Obama on the Affordable Care Act. Courtesy WikiMedia Commons and whitehouse.gov

The signature of President Obama on the Affordable Care Act. Courtesy WikiMedia Commons and whitehouse.gov

When health care reform was signed into law in 2010, many Democrats wary of being identified with “death panels” dropped all proposals associated with end of life planning, despite support from many medical professionals, caregivers and ethicists.

According to Politifact, a Pulitzer Prize-winning fact checker, comparing end of life counseling to “death panels” was 2009′s “Lie of the Year.” Former vice presidential candidate and Alaska governor Sarah Palin was the first to coin the term “death panels” on her Facebook page after the release of an early draft of the bill. Some conservatives charged that vital care would be cut off to the aged and ill if doctors recommended they receive less aggressive treatments.

Karen N. Long, president of the Chicago End-of-Life Care Coalition, said she believes patients will benefit from one-on-one conversations with doctors about their “goals of care.”

“Everyone in this field has been working on this for a long time. It’s very much needed, because it helps patients think about what’s important to them, what they consider a ‘good’ quality-of-life,” Long told LMM. “I think most of the controversy goes back to the conflated issue of ‘death panels,’ where some individuals misquoted and misunderstood what was in the proposed law.”

An advance health care directive may take the form of a living will, power of attorney or the Five Wishes collection. The overall purpose of such forms is to help ensure that one’s end of life wishes are carried through in case of illness or incapacity.


Hospice Patients More Likely To Be Discharged From For-Profit Programs

Posted on Wednesday, August 13th, 2014 at 8:49 am by lifemediamatters

Courtesy Creative Commons By Denise Mayum

Courtesy Creative Commons By Denise Mayum

Nearly 20 percent of U.S. hospice patients are discharged before death, according to new findings published in the Journal of Palliative Medicine. Not-for-profit and government-owned hospices had lower rates of live discharge than newer for-profit programs.

The researchers, led by Dr. Joan Teno, associate director of the Center for Gerontology and Health Care Research at Brown University Medical School, found that nearly 200,000 of the one million hospice patients discharged in 2010 were still alive (18 percent). Connecticut had the lowest rate of live discharge (13 percent), and Mississippi had the highest (41 percent).

“When you have a live discharge rate that is as high as 30 percent, you have to wonder whether a hospice program is living up to the vision and morality of the founders of hospice,” Teno told The Washington Post. “One part of the reason is some of the new hospice providers may not have the same values — they may be more concerned with profit margins than compassionate care.”

Patients in nonprofit programs were less likely to be discharged while alive than those in similar for-profit programs: 15 percent to 22 percent. More mature programs (those 21 years and older) had lower rates of discharge than those in operation for 5 years or less: 14 percent to 27 percent. “There has been a striking increase in the number of hospice providers with the fastest growth coming from for-profit providers,” authors write.

Hospice care is designed to help comfort the seriously ill near the end of life, and it has become increasingly popular in recent years – reaching nearly $14 billion in payments during 2011. The Medicare hospice benefit, established in 1982 to help patients pay for care, is usually provided only to those with a life expectancy of six months or less. All Medicare hospice discharges between January 1 and December 31, 2010 were analyzed.

The researchers said they are concerned by variation between hospice programs and its effect on patients’ quality-of-life.

“The provider and state variation raises concern that live discharges are not driven by patient preference but by provider and market behavior,” they add. Hospice programs that exceeded their reimbursement caps — a marker for hospices with an excessive average hospice length of stay — had double the rate of live discharges compared to hospice programs that did not exceed their cap.

One in four discharged patients were hospitalized within 30 days, and more than 7 percent were immediately hospitalized and reentered hospice.

Historically, about 15 percent of hospice patients have been discharged for a variety of reasons, including the choice to restart curative treatments. But researchers suggest some newer hospice programs have accepted patients too early and discharging others when costs of their care has risen.

In February, Illinois-based Passages Hospice, LLC was shuttered amidst federal fraud charges. The for-profit hospice, which served hundreds throughout the Midwest, allegedly over-billed Medicare and provided patients unnecessary care.


Medicare Revises Hospice Drug Policy, Local Providers Relieved

Posted on Tuesday, July 22nd, 2014 at 7:39 am by lifemediamatters

Under nationwide pressure from hospices experiencing financial and administrative strain due to a newly implemented policy, the Centers for Medicare and Medicaid Services is revising its own guidance that was intended to help avoid duplicate payments for prescription drugs. This change of course comes two months after the CMS rule’s effective date, months in which providers say the policy jeopardized patient access to end of life care.

SyringeIn May, CMS began to require a prior authorization process for hospices and Medicare Part D providers in order to determine responsibility of drug coverage. Hospices were charged with covering medications not related to the hospice, or terminal, diagnosis. Previously, hospices paid only for drugs needed for symptom management, and Part D policies covered medications for hospice patients’ unrelated conditions.

“Based on discussions with stakeholders, we are adjusting our rules so that beneficiaries enrolled in hospice will continue to have access to their medications while balancing recommendations by the Inspector General meant to safeguard the Medicare program,” said Raymond Thorn of the CMS Office of Communications.

The Office of the Inspector General had recommended the policy’s implementation to minimize mistakes in which Part D plans covered hospice drugs. However, the more than 40 healthcare organizations and hundreds of hospice providers that have lobbied against the rule in recent weeks maintain it unduly burdened beneficiaries, requiring dying patients to navigate payer disputes.

“CMS listened when they convened all the various stakeholders, and heard a unified message focused on protecting beneficiaries from an onerous and insensitive prior authorization process,” said Jonathan Keyserling, Senior Vice President of the National Hospice and Palliative Care Organization. “The announcement of significant modifications in the previous guidance will greatly relieve the stress that patients and families, as well as providers, were experiencing under the prior flawed process.”

Under the revised policy, CMS expects Part D sponsors to use hospice prior authorization only on four drug catagories typically covered under the hospice benefit. They include analgesics, anti-nauseants, laxatives and anti-anxiety medications.

“Barriers to access should be minimized,” Thorn said, as the number of these claims are expected to be minimal.

Providers say the original guidance lengthened admission processes; they maintain it often deterred patients from hospice support if medications taken for decades, psychiatric drugs for example, would not be covered upon enrollment.

“We had changed our admission documentation, and we were starting to have those conversations with new admissions,” said Greg Zrazik, Chief Financial Officer of Angels Grace Hospice in Chicago’s southwest suburbs. “We have been looking at the drugs, trying to determine what we felt we would pay for, what would be paid for by Part D and aggressively looking at things they could consider stoping or could pay for themselves.”

Angels Grace has experienced a 30 percent uptick in drug costs since the rule took effect. Serving 45 patients a day, the hospice experienced a “huge burden” that threatened its financial future; average daily Medicare hospice reimbursement is $160.

“This puts things back to if hospices are doing the right thing, we would certainly recommend a patient come off of drugs that aren’t appropriate,” Zrazik said. “But we don’t have to be aggressive, or make patients make difficult decisions.”

Hospices may realize instant efficiency as a result of this revision, providers say.

“We don’t have to be focused so much on the rigamarole of all the paperwork, and instead we can think more about what the patient and family needs and spend time with them,” said Martha Twaddle, medical director of Journeycare, a hospice serving 500 patients daily across northern Illinois.

Time and personnel are the most important resources a hospice has, said Twaddle, and the extra work the guidance required was threatening the long-term sustainability of quality bedside care.

The tone of the CMS guidance and the agency’s willingness to reverse course are encouraging to end of life care providers.

“If we are going to do good care for Americans, we have to be working together, changing models of delivery and be willing to change ourselves,” Twaddle said. “This is a fabulous sign.”


Passages Hospice Responds To Health Fraud Charges Against Founder

Posted on Thursday, February 6th, 2014 at 8:18 am by lifemediamatters

As Passages Hospice founder and owner Seth Gillman faces federal fraud charges, employees of the for-profit Illinois health care company are vowing to continue providing care to their terminally ill patients.

Gillman has been charged with both health care fraud and obstructing a federal audit. According to prosecutors, Gillman knowingly over-billed the government for hospice care provided to seniors across the state.

According to the charges, Gillman engaged in an elaborate scheme to obtain higher Medicare and Medicaid payments by fraudulently elevating the level of hospice care for patients, many of whom resided in nursing homes he controlled. Some patients were not terminally ill, and they wound up enrolled in hospice care far longer than the required estimated life expectancy of six months or less.

Kansas Swain, Passages public relations director, said Gillman has “stepped away” from the company.

“Mr. Gillman will have to answer for the allegations that have been placed against him, but Passages has been cleared,” Swain said.

Gillman also allegedly trained nurses to look for signs that would qualify a hospice patient for general inpatient care (GIP). For fiscal year 2012, Medicare’s daily reimbursement for GIP was $671.84; the daily payment for routine care was much lower, at $151.23.

From 2006 to late 2011, Passages submitted claims for about 4,700 patients to Medicare and Medicaid. The company received payments of  approximately $95 million from Medicare and approximately $30 million from Medicaid.

Gillman, freed on $150,000 bond, faces 15 years in prison and $500,000 in fines. From March 2009 through April 2011, he allegedly authorized nearly $850,000 in bonuses for himself.

Swain, who described Gillman as a “hard-working” man with an “innovative vision,” said it was difficult for the hospice staff to learn of the allegations.

“The most important thing to him was the patients,” Swain said. “We want to move forward and restore public trust. Nothing has been interrupted.”

According to the FBI, federal agents have interviewed patients, family members and more than 30 former and current employees of Passages, including several who reported allegedly fraudulent billing and marketing practices to Medicare or law enforcement.

Passages Hospice Founder Faces Federal Health Fraud Charge

Passages Founder Faces Federal Health Fraud Charge

The allegations have created a chilling effect on other Illinois hospices.

Jeff Okazaki, communications director for Rainbow Hospice and Palliative Care, a non-profit, said he was not surprised by the allegations.

“Unfortunately, it is something that we’ve seen in the industry across the board now with a lot of the big, for-profit hospices facing lawsuits with these sorts of charges,” Okazaki said.

Rainbow Hospice advises that patients and families look for accreditation before enrolling, specifically from the Community Health Accreditation Program (CHAP). “Anybody can deliver quality hospice care, but it really comes down to the priorities,” Okazaki added.

Hospice is generally care provided in a patient’s home, but it can also be provided in a hospital, nursing home or other long-term care facility for those at the end of life. The number of hospice patients served nationally has risen more than 25 percent over the last five years from 1.25 million in 2008, according to figures published by the National Hospice and Palliative Care Organization.

Okazaki said patients enrolled in hospice should be reviewed about every 90 days by a physician or nurse practitioner to ensure that they are terminal and thus eligible for hospice benefits. Medicare may request documentation about patients enrolled in hospice.

Mary Runge, president of non-profit Horizon Hospice & Palliative Care, said that her biggest concern in the wake of these charges is public perception.

“When something like this happens, it hurts everybody,” Runge said. “I realize these are allegations, but this is not the way the majority of hospices operate. We follow the Medicare rules and regulations.”

She said the alleged conduct at Passages is not reflective of any practice in the industry. “There are so many wonderful hospices in the area,” Runge said. “Whether you are for-profit or not-for-profit, you have to follow the guidelines- and go beyond them, frankly.”

Dr. Balu Natarajan, chief medical officer with Seasons Healthcare Management Inc., said Medicare guidelines require its interdisciplinary team to meet every two weeks to determine an individualized care plan for every patient enrolled in the for-profit hospice program.

“At Seasons, we follow the Medicare guidelines when determining if a person qualifies for the Medicare hospice benefit,” Natarajan said. “The basic principle: two physicians must certify terminal illness, specifically noting that life expectancy is less than six months. Certain diseases have more specific admission and recertification guidelines, according to Medicare. We follow those admission and recertification guidelines diligently.”


Passages Hospice Founder Faces Health Fraud Charges

Posted on Wednesday, January 29th, 2014 at 5:51 am by lifemediamatters

Seth Gillman, founder and partial owner of Passages Hospice LLC, has been charged with health care fraud. According to prosecutors, Gillman knowingly over-billed the government for hospice care for Illinois seniors.

“Give patients everything they need, even that little extra that makes life worth living,” Gillman told Life Matters Media in November during the unveiling of an end of life care initiative backed by the National Institute for Nursing Research. But according to the fraud charges released Monday, federal prosecutors allege Gillman was not so selfless.

According to the charges, Gillman engaged in an elaborate scheme to obtain higher Medicare and Medicaid payments by fraudulently elevating the level of hospice care for patients, many of whom resided at nursing homes he also controlled across the state. Some patients were not terminally ill, and they wound up enrolled in hospice care far longer than the required life expectancy of six months or less.

Gillman also allegedly trained nurses to look for signs that would qualify a hospice patient for general inpatient care (GIP). For fiscal year 2012, Medicare’s daily reimbursement for GIP was $671.84, while the daily payment for routine care was much lower at $151.23.

From 2006 to late 2011, Passages submitted claims for about 4,700 patients to Medicare and Medicaid and was paid approximately $95 million from Medicare and approximately $30 million from Medicaid. Between July 2008 and late 2011, Passages was paid $23 million by Medicare for GIP services, in addition to Medicaid payments for similar services submitted on behalf of about 200 patients.

Gillman, 46, of Lincolnwood, IL was charged with one count each of health care fraud and obstructing a federal audit in a criminal complaint that was filed in U.S. District Court late last week.

Gillman, an attorney who founded Passages after witnessing his grandmother’s poor end of life care in a hospice in south Florida, is the corporate agent, administrator and one-fourth owner of Lisle-based Passages Hospice LLC. He is the agent and secretary of Asta Healthcare Company Inc., which operates a handful of Asta Care Center nursing homes across the state– Passages did not have its own inpatient facility but instead deployed nurses to visit hospice patients in nursing homes and private residences.

Passages is a fast-growing care network

Passages is a fast-growing care network based in Illinois

Passages declined to return numerous phone calls from Life Matters Media seeking comment. The hospice’s website makes no mention of Gillman’s legal troubles; the company’s official Twitter account continues to advertise their services.

“The complaint was brought only against Seth Gillman, not Passages,” said Katten Muchin Rosenman Partner Gil Soffer, who represents Passages, in a statement to LMM. “The period of alleged misconduct set forth in the complaint ended in January 2012, more than two years ago. The company continues to provide high quality care to its patients.”

According to the FBI, federal agents have interviewed patients, family members and more than 30 former and current employees of Passages, including several who reported allegedly fraudulent billing and marketing practices to Medicare or law enforcement.

If convicted of health care fraud, Gillman could face a penalty of 10 years in prison and a $250,000 fine. If convicted of obstructing a federal audit, Gillman could face up to five years in prison and a $250,000 fine.

Hospice is generally care provided in a patient’s home, but can also be provided in a center, hospital, nursing home or other long-term care facility for people facing illness near the end of life. The number of hospice patients served has risen more than 25 percent over the last five years from 1.25 million in 2008, according to figures published by the National Hospice and Palliative Care Organization in the organization’s 2013 annual publication “Facts and Figures: Hospice Care in America.”