Medicare Revises Hospice Drug Policy, Local Providers Relieved

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.”


Diane Meier: Palliative Care Improves Quality Of Life, Reduces Medical Spending

Posted on Thursday, December 5th, 2013 at 5:21 pm by lifemediamatters

Half of older Americans visit emergency departments in their last month of life; 75 percent in last six months of life 

Palliative medicine helps improve quality of life and reduces unnecessary spending on emergency care for the chronically ill, said Dr. Diane Meier, director of the Center to Advance Palliative Care and a professor of medical ethics at the Icahn School of Medicine at Mount Sinai. Meier was the keynote speaker for “Palliative Care: A Major Paradigm for Care Coordination,” a conference presented by the Illinois Hospital Association in Naperville Thursday.

Mr. and Mrs. B

Mr. and Mrs. B, Courtesy IHA

Meier opened her lecture with the true story of an elderly couple struggling without palliative support:

Mr. B is an 88-year-old man suffering mild dementia and admitted to the hospital via the emergency department for management of back pain due to spinal stenosis and arthritis. His pain is an 8 on a scale of 10 upon admissionhe receives 5 grams of acetaminophen (Tylenol) each day. He has been admitted three times in two months for pain, weight loss, falls and altered mental status due to constipation. His 83-year-old wife is overwhelmed.

“He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do,” Mrs. B told Meier.

Meier pointed out to an audience of palliative care nurses and other medical professionals that among Medicare enrollees in the top spending quintile, nearly half have chronic conditions and functional limitations, just like Mr. B. Most of the costliest 5 percent of Medicare enrollees (61 percent) suffer from similar conditions. Nationally, spending on dementia-related services totaled nearly $215 billion in 2010.

“The emergency department has become the modern death ritual in the U.S.,” Meier added, because half of older Americans visit the emergency department in their last month of life, and 75 percent do so in their last six months.

According to Meier, a palliative care strategy with geriatric support could have helped Mr. and Mrs. B manage symptoms more adequately, and it could even have helped them avoid some unnecessary hospitalizations. “What we need to do is get out of our taxonomy silos, specialty driven silos,” Meier said. “Because of the concentration of risk and spending, palliative care principles and practices are central to improving quality and reducing cost.” The costs of Mr. B’s four most recent hospital visits totaled several hundred thousand dollars. But the Bs did not do anything wrong, Meier said, because the medical system encouraged their situation. What else could they do?

Meier suggested more home and community-based services to help reduce the number of seniors who find themselves in situations like the the couple– lacking an able-bodied caregiver and without an easily accessible medical provider. “Staying home is concordant with people’s goals, she said. “Based on 25 state reports, costs of home and community-based long term care services are less than one-third the cost of nursing home care.” For example, in a study published in the journal Health Affairs, researchers determined that simply having meals delivered to a senior’s home significantly reduced the need for a nursing home.

As HealthDay News reported: “If all 48 contiguous states increased by 1 percent the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care.” Still, the U.S. lags behind every other industrialized nation when it comes to the ratio of social to health service expenditures.

Meier Graph

Hope Brown, a nurse with the Carle Foundation Hospital in Urbana, IL, said she appreciated Meier’s attention to the costs of care and the need for social support. “It happens every day, situations like the Bs. We definitely need to get people into social services earlier, even meal delivery,” she added.

Overall, Meier urged medical professionals to “treat the person, not the disease.” Since most patients prefer to live at home and remain independent, (76 percent rank “independence” as most important, followed by pain and symptom relief, and staying alive last) palliative medicine should reflect those wishes.

Diane Meier, Courtesy WikiMedia Commons

Diane Meier, Courtesy WikiMedia Commons

View “Palliative Care in the Mainstream: Stepping Up to the Plate”


Short Hospice Stays May Mean Lack Of Awareness, As NHPCO Launches First National Campaign

Posted on Tuesday, December 3rd, 2013 at 10:16 am by lifemediamatters

Image courtesy Tennessee Hospice Organization

Image courtesy Tennessee Hospice Organization

Despite the growing number of Americans seeking end of life care, the number of short stays in hospice is troublesome, and a sign that caregivers and the hospice industry see as a major lack of awareness about a key service for the dying.

A new report from the National Hospice and Palliative Care Organization (NHPCO) shows that more than one in three hospice patients (35.5 percent) died or were discharged within seven days of admission last year. That rate was largely the same as in 2011.

NHPCO’s analysis comes as usage of hospice, however, is on the rise. More than 1.5 million patients with a “life-limiting illness” were admitted to hospice last year, at a time of greater need- with an aging population of baby boomers eligible for the Medicare health insurance program for the elderly.

“Many physicians and hospitals don’t refer those patients until the end. Some don’t refer because it interrupts their own reimbursement or the physician’s.”

“There’s an awareness problem,” said Donald Schumacher, president and chief executive officer of National Hospice and Palliative Care Organization (NHPCO) in an interview with Life Matters Media. “People are always struggling when it is going to be the end of life.”

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 NHPCO figures published in the organization’s 2013 annual publication “Facts and Figures: Hospice Care in America”

Caregivers say the industry needs to do a better job at outreach and education to medical professionals and the public at large, particularly given the benefit is adequately funded by the Medicare health insurance program for the elderly and disabled, which offers access to hospice to potentially millions of Americans.

Schumacher said there can be many reasons for the lack of service and related knowledge about a benefit designed for patients with a prognosis of six months or less, assuming their disease follows its normal progression. Patients can remain in hospice if they live longer, pending a physician’s analysis for continued eligibility, hospice providers say.

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“Many physicians and hospitals don’t refer those patients until the end,” Schumacher said. “Some don’t refer because it interrupts their own reimbursement or the physician’s.”

Though the number of patients with short lengths of service is a concern, the average length of service, or length of stay, continues to rise. In 2012, the average length of service was 71.8 days compared to 69.1 days in 2011.

“As hospice and palliative care professionals, we need to continue reaching out to patients and family caregivers to help them understand all the benefits that hospice care brings,” Schumacher said in a statement NHPCO released to accompany its report. “And as part of our ongoing engagement efforts, we must continue our efforts to reach communities that are under-utilizing hospice care.”

To improve awareness about hospice and the services it provides, NHPCO is launching a first-ever national campaign. Though NHPCO executives are not ready to disclose details, they did confirm the campaign will be a “multi-million-dollar” effort launching in January.

Certainly, hospice facilities have a financial interest in making patients and their families aware of this benefit.

But meanwhile in Washington, the sequester has already slashed Medicare and other government spending on an array of programs – including hospice – and providers don’t want to give Congress another reason to reduce spending on a service studies show is needed. This year, hospice had Medicare reimbursement of nearly $160 per day reduced to $156, a payment that covers professional staffing such as nurses, therapists and social workers.

Still, Schumacher said Congress is supportive of the hospice benefit and said it fits the push by the Affordable Care Act and government health insurance programs to keep patients in high quality, low cost settings rather than in more expensive inpatient hospital settings.

“There is Medicare funding for hospice,” Schumacher said.

“We are a huge savings,” he said of hospice care. “Hospice saves on average about $2,300 in comparison to other patients who are admitted for similar illness” to other facilities like hospitals.

The Medicare hospice benefit is the primary source of coverage for hospice care. In 2012, 83.7 percent of hospice patients were covered by Medicare, the NHPCO study showed.

Schumacher said hospice programs are becoming more integrated in newer healthcare delivery models designed to help save Medicare dollars, while at the same time improving quality such as accountable care organizations (ACOs) that have contracts with Medicare to coordinate treatment in hopes of improving outcomes while lowering the cost of medical care.

This fall in Detroit, for example, Hospice of Michigan partnered with Genesys Physician Hospital Organization’s ACO.

The ACO model differs from the predominant fee-for-service medicine in which medical providers are paid for each service for each patient in a system. Fee-for-service medicine can lead to potentially excessive treatment. When it comes to end of life care, patients are known to get a lot of care, but it is often not coordinated.

Genesys Physician Hospital Organization’s ACO was one of the original 32 so-called “pioneer ACOs” that were launched by Medicare’s administrator, the Centers for Medicare & Medicaid Services.

“By offering additional support early on to those suffering from serious illness, we are able to better manage symptoms and relieve pain,” Dottie Deremo, president and chief executive officer of Hospice of Michigan, said in a statement announcing the new partnership. “This type of care provides the patient with comfort, helps relieve stress and anxiety and extends the patient’s quality of life.”

View the full report