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

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


Hospice Use: New Facts and Figures

Posted on Tuesday, November 12th, 2013 at 9:36 am by lifemediamatters

In 2012, 1.6 million Americans received hospice care; 36 percent died or were discharged within seven days of admission.

Image: 'Love' by Denise Mayumi via Flickr

‘Love’ by Denise Mayumi

New findings published in the annual hospice facts and figures report show nearly 80 percent of hospice patients receive care for less than 90 days before dying. The median length of a hospice stay is only about 19 days, and the findings are both consistent with those of 2011 and troubling to study researchers.

The report, “Facts and Figures: Hospice Care in America,” was conducted by National Hospice and Palliative Care Organization. It provides data on hospice trends and updated information on the growth, delivery and quality of hospice care throughout the U.S.

“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,” said NHPCO President and CEO J. Donald Schumacher, Psy.D in a press release. “As part of our ongoing engagement efforts, we must continue our efforts to reach communities that are under-utilizing hospice care.”

Hospice Use

Hospice is care that aims to provide comfort and pain management rather than aggressive treatments– usually only for terminally ill patients with six months or less to live. It is most often used when curative treatments are no longer effective. Cancer remains the most common diagnosis for patients seeking hospice; 37 percent of enrollees are cancer patients.

Sixty-six percent of patients who receive hospice benefits remain in the place they call home, whether it be a private residence or nursing home, unchanged from 2011. The gender divide between hospice patients also remains unchanged; 56 percent of hospice patients are female.

Since the founding of the first American hospice in 1974, more than five thousand hospice programs have opened throughout the U.S. The Medicare hospice benefit, enacted by Congress in 1982, remains the predominant source of payment. Eighty-four percent of patients receive coverage through the benefit.


Under Obamacare, Hospice Providers Will Soon Have Incentive To Improve Quality

Posted on Monday, July 29th, 2013 at 10:56 am by lifemediamatters

A new era for hospice care begins this fall, as medical providers must report quality measures to the U.S. government on the care they provide or face financial penalty.

Though the hospice quality reporting program is in its early stages, the Obama administration and supporters see it as a way to improve end of life care and treatment when data is reported- with providers potentially benefiting from feedback in how they measure against their peers in the hospice industry.

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

Under the Affordable Care Act, Congress built in a number of measures and programs across all health care provider groups designed to improve the quality of medical care and potentially reduce costs, including the new “Hospice Quality Reporting Program.”

It’s the latest quality push from the Centers for Medicare & Medicaid Services — which pays for most hospice care in the U.S. via the health insurance program for the elderly and is therefore charged with rolling out the hospice quality reporting initiative– to move toward reimbursing providers for quality care and outcomes given and move away from fee-for-service medicine. The latter practice allows providers to get paid no matter the quality of care, and studies show fee-for-service medicine may lead to unnecessary or overused treatments.

“CMS’s goal is to adopt measures for the Hospice Quality Reporting Program that ensure care is patient and family-centered and is safe and high-quality,” Dr. Patrick Conway, chief medical officer and director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services said in a statement to Life Matters Media. “It is critical that hospice providers meet the care needs of all patients and families.”

The Obama administration has already rolled out quality measures for other providers of medical care as well as insurance companies, known as “Advantage plans,” that contract with Medicare to provide medical health benefits to seniors. The health plan quality program includes a star rating system to provide payment bonuses for higher-scoring plans, therefore giving consumers a better idea of which health plans seniors should choose.

For now, the hospice reporting program isn’t nearly as far along as the quality measures in the health insurance industry, nor is there an established way for the public to access what is reported to the government. However, it is believed that more information about quality will eventually lead to better care- once the data is compiled and reported back to hospice providers.

“The Affordable Care Act requires that CMS use nationally endorsed quality measures, but also allows CMS to specify measures that are not already endorsed if a feasible and practical measure in the area determined appropriate by the Secretary (of Health and Human Services) has not been endorsed,” the Centers for Medicare & Medicaid Services reports on its site for the quality reporting system, which is linked here. 

One major quality measure that hospice providers must report regards pain- a critical problem for patients at the end of life. The “pain measure reflects the number of patients who report being uncomfortable because of pain at the initial assessment (after admission to hospice services) who report that pain was brought to a comfortable level within 48 hours,” the CMS web site states.

Providers are asked myriad questions, such as the so-called initial comfort question:  “Are you uncomfortable because of pain?” That is asked at the time of the patient’s initial assessment.

Then, patients are asked a follow-up question as to whether their pain was “brought to a comfortable level within 48 hours of the start of hospice care?” That question is asked “within 48 to 72 hours after initial pain assessment,” according to the hospice data reporting protocol.

Providers say more questions and follow-up reporting on hospice quality could lead to improved care and potentially better diagnosis and intervention well before a patient is in need of end of life treatment. The Centers for Medicare & Medicaid Services is increasingly asking hospice providers for more and more information about the diseases patients had before they came to hospice, such as heart disease, cancer or Alzheimer’s.

Some see the additional information and quality reporting system as a way to move the government and private insurance companies further away from paying for just the quantity of hospice care delivered to paying for quality of the care at the end of a patient’s life and the performance of the medical providers who give the care during these final days.

Additionally, the quality metrics seem to encourage medical-care coordination, which some medical care providers say may one day lead to better outcomes if they can use the data to analyze diseases that put the patients into hospice care in the first place.

“We might be able to better identify diagnoses,” Julie Shackley, president and chief executive officer of Androscoggin Home Care & Hospice in Lewiston, Maine, said of the additional information being requested by the Centers for Medicare & Medicaid Services. “Are we seeing more patients with congestive heart failure? We may be able to better understand cardiac care.”

The National Hospice and Palliative Care Organization reports it “fully supports quality reporting,” though it has caused a “significant additional expenditure of resources over a short period of time” for providers, NHPCO senior vice president of health policy Jonathan Keyserling said in a statement to Life Matters Media.

A comment period on numerous new regulations facing medical care providers just ended this summer, so there could eventually be changes to the reporting program. But the current plan has already required providers to collect data from October to December of last year and submit it earlier this year. Financial penalties of a 2 percent decrease in reimbursement begin in fiscal 2014, which begins October 1 this year.

“The timeline that CMS has proposed for putting new measures in place is very ambitious and comes at a time when hospices are already dealing with reductions in payment,” NHPCO’s Keyserling added. “Quality reporting adds significantly to their burden. We encourage CMS to be aware of the many demands facing the hospice community and to continue to work constructively with NHPCO to try and reduce unnecessary burdens as much as possible.”


Duty Of Physicians To Inform Patients Of Hospice, Palliative Care

Posted on Saturday, June 1st, 2013 at 1:11 pm by Life Matters Media

Physicians have an ethical duty to inform their patients facing end of life about hospice and palliative care services, said Dr. Frederick Smith, director of clinical ethics at North Shore-LIJ Health System.

Smith

Dr. Frederick Smith

Smith’s presentation, part of the University of Chicago’s second annual Conference on Medicine and Religion, criticized the choices of many physicians who urge their patients to continue with more aggressive, painful treatments instead of more comfortable end of life care. Drawing inspiration from Judaism, Christianity and Islam, Smith suggested hospice and palliative care are compatible with religious teachings about death and pain. “A central function of religion is to provide meaning and consolation,” he said.

There are two things a failing patient needs to accomplish the “work of dying”: consciousness and time, Smith said. Dying allows patients time for reflection about life and opportunities for reconciliation. “Jesus wants his followers to seek reconciliation,” Smith said, noting the Lord’s Prayer.

“The Prophet Muhammad placed great value on forgiving the poor man’s debt,” Smith said. “The sacred books of the three great traditions, which originated with God’s call to Abraham, summon their adherence to a righteous life, comprised with loving adherence to God and honorable treatments to family, neighbors and even strangers. They teach that death is not the end.”

Hospice is most often used when curative treatment is no longer effective and a terminal patient is expected to live about six months or less. Palliative care is treatment that enhances comfort and improves the quality of life for patients. When deteriorating persons are not allowed time to begin the “work of dying,” they are more likely to leave feuds and conflicts unresolved, often carried on with the next generation. ”Feuds should not be taken to the grave,” Smith said.

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One-third of hospice patients are too frail to begin the “work of dying,” because they are too frail, Smith said. They are transferred to hospice too late, only after aggressive treatments fail. Medicare reimburses for hospice care for up to six months, with extensions for failing patients who continue beyond six months.

Findings published in the Journal of the American Medical Association show hospice is often a last resort.

“Clinicians frequently ignore conversations about the likelihood of survival. If patients with life ending conditions truly knew the end was coming, would not it be better to take advantage of hospice?” Smith said.


Palliative Medicine, Hospice Care?

Posted on Tuesday, December 4th, 2012 at 7:50 pm by Life Matters Media

Despite its growing popularity in hospitals, most Americans remain unaware of the comfort and benefits palliative care can provide some terminally ill patients.

“There is a clear need to inform consumers about palliative care and provide consumers with a definition of palliative care,” researchers commissioned by the Center to Advance Palliative Care advise. According to Public Opinion Research on Palliative Care, seventy percent of the general population doesn’t know anything about palliative care, and 14 percent were “somewhat knowledgeable.”

The researchers also found that it is difficult to inform physicians about palliative care, because they often wrongly equate it with hospice or end of life care.

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Palliative care becoming more popular

Palliative care is treatment that enhances comfort and improves the quality of life for patients in life’s last phase. No therapy is excluded from consideration, according to the National Hospice and Palliative Care Organization (NHPCO).

Palliative care is becoming increasingly widespread. There are more than 1,600 hospitals that have palliative care programs in the U.S., according to Dr. Diane Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine. Some 85 percent of large hospitals have a palliative care team. Sixty-seven percent of small hospitals have programs.

Dr. William H. Frist, a heart transplant surgeon and former U.S. Senate Majority Leader, recommends palliative care. ”[A] brand new field in medicine is making chronic, agonizing, and even terminal illnesses much more manageable… palliative care has emerged as the best solution for those facing serious, painful diseases, and introduces the very real possibility… that we can now live with these diseases for a long time,” he wrote recently for The Week.

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Palliative care also costs much less than aggressive end of life regimens. Patients who receive palliative care services cost hospitals between $1,700 and $5,000 less per admission, according to findings published in the Archives of Internal Medicine.

Hospice care remains overlooked

Hospice care is different from palliative care; its aim is to manage symptoms so that a person’s last days are spent with dignity and quality. The care is not intended to treat the disease but the person, according to the American Cancer Society.

Hospice is most often used when curative treatment is no longer effective, and a terminal patient is expected to live about six months or less.

“Many people believe that hospice is only for people who have cancer. This may be due to the fact that many of the patients cared for in the early days of hospice were cancer patients,” Becky Hillier, public relations director for Rocky Mountain Hospice, wrote for the Montana Standard. Less than 25 percent of hospice patients admitted to the hospice are cancer patients.

The NHPCO reports that 36 percent of hospice patients die or are discharged within seven days of treatment. Many terminally ill suffer more than they need to because they wait to enroll in a hospice program.

“We continue to see more dying Americans opting for hospice care at the end of their lives, yet far too many receive care for a week or less,” said the NCPCO’s J. Donald Schumacher. “We need to reach patients earlier in the course of their illness to ensure they receive the full benefits that hospice and palliative care can offer.”

One reason the terminally ill wait for hospice, he said, is due to the misconception that hospice means giving up.