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.”

Drug Policy Places New Pressures On Hospice

Posted on Wednesday, July 2nd, 2014 at 9:13 am by lifemediamatters

This piece was first published in Voices in Bioethics. LMM President Randi Belisomo is a contributor.

The Policy

After outcry over a new rule intended to help avoid duplicate payments for medications of hospice beneficiaries, the Centers for Medicare and Medicaid Services met June 25th with representatives of thirty hospice organizations, who argue they now face financial burdens that are not theirs to bear.

The rule took effect in May, requiring a prior authorization process for hospices and Part D providers to determine responsibility of drug coverage. Hospices must now cover medications unrelated to the hospice diagnosis. Previously, Part D providers covered drugs for hospice patients’ unrelated conditions,while hospices covered only those drugs for symptom management.

The CMS guidance, entitled “Part D Payment for Drugs for Beneficiaries Enrolled in Hospice,” resulted from a recommendation of the Office of the Inspector General. In 2012, the OIG exercised oversight to examine Medicare hospice patients whose drugs were sometimes paid for by Part D rather than by the hospice. Errors occurred in some instances, and Part D plans had been used to pay for drugs that fell under the responsibility of hospices.

Courtesy WikiMedia Commons

Courtesy WikiMedia Commons

More than 40 organizations- including the American Medical Association, the American Society of Clinical Oncology, and the American Geriatrics Society- issued a letter to CMS Administrator Marilyn Tavenner on June 23rd, calling for the suspension of this policy. Signatories expressed concerns that the rule places beneficiaries at the center of potential disagreements between hospice providers and Part D plans– “requiring dying patients to navigate payer disputes.” It outlines a need for greater clarity in a policy “subject to differing interpretation, and already creating barriers for dying patients who are trying to access necessary medications.”

The signatories cite reports of patients already paying out-of-pocket for medications, going without medications they need, or revoking the hospice benefit in order to access medicine through Part D.

Though a spokesperson for the National Hospice and Palliative Care Organization says members are “pleased” CMS heard concerns, there was “no indication” that any amendments to this new guidance would be made.

Its Implications

While CMS quite validly seeks to ensure the appropriate entities pay for appropriate medications, there exists equally valid concern among providers that such a policy could impact access to quality end-of-life care. The impact is currently being felt financially and administratively, and the implications raise ethical concerns about the future of hospice access.

Financial: The operational strain the CMS guidance places on hospices is tremendous, as providers are responsible for coverage of medical care, social services, nursing visits, chaplaincy, and other support in patient homes, for an average Medicare reimbursement of 160 dollars daily. Added bureaucracy and costs are not pressures hospices are structured to absorb, as typical margins are extraordinarily tight.

Angels Grace Hospice, which serves roughly 45 patients daily in Chicago’s southwest suburbs, has experienced a 30 percent increase in drug costs during the past month. It is covering all drugs while the situation is assessed; a policy Chief Financial Officer Greg Zrazik calls a “fairly liberal, compassionate approach.”

Since only a matter of weeks has passed since its effective date, an accurate financial strain has yet to be measured. “When you have a certain model in anticipation of cost structure and have the situation change, it requires some shifting and adapting and being creative,” Zrazik says. “You’re going to see a more aggressive policy with new patients to assess all medications they are on and look to aggressively discontinue as many drugs as possible when they come on hospice.”

Such an uptick in drug costs threatens the existence of small to mid-sized hospices throughout the U.S. Rural hospices, in particular, do not enjoy large patient censuses and are responsible for covering large geographic areas. Such a substantial new line item is not one such providers can comfortably cover.

Dr. Martha Twaddle, medical director of Barrington, Illinois-based JourneyCare, says she is concerned about what some hospices may do to survive. “In the past, we may have allowed a patient to continue on a medication rather than engage in a negotiation. Now, because of this financial pressure, some hospices will be forced to be more forthright in stopping medications not shown to be helpful,” Twaddle says.

Financial pressures, however, may impact the supply of medications that are actually needed. “They may try to substitute less expensive medications that are not as effective, and you don’t want to be monkeying around when someone is dying,” she says.

Administrative: The interest of Part D plans is not always best served by expediency. Theresa Forester, of the National Organization for Home Care and Hospice, says the opportunities for misunderstanding are numerous- and of concern to patients and families.

“There are incentives in the system that could lead Part D plans to drag their heels in terms of coverage, because in some instances, someone else might pick up the tab,” Forester says. “If there is a delay in payment, oftentimes family members will step up and pay out-of-pocket.” As patients and their families await resolutions in payer disputes, those families able to afford medication may feel urgency to cover drug costs themselves. Those unable to afford the coverage may face unnecessary stress or pressure to purchase medications and worry about the bill later– in some instances, arriving after a loved one’s death.

JourneyCare reports the average length of time for admissions visits has increased, and case managers and interdisciplinary teams must spend more time in homes sorting through medications and explaining to patients what medications may or may not be necessary. Penny Murphy, Vice President of Quality and Compliance, says much work is being done to proactively communicate with Part D plans. “I think the smaller programs have not had the resources to reach out and make those decisions,” Murphy says.

If patients are asked to stop medications they have been using for years – and aren’t receiving thorough explanations about the reasons why that drug for a thyroid condition may not be so important after a hospice enrollment – such administrative lack of capacity could cause undue stress or confusion. “Why do we need to add more stress when people are in a time of tough decisions?” Twaddle asks. “It’s just one more hoop to jump through.”

Access to Care: While some smaller hospices, such as Angels Grace, report decisions to cover all medications in these first weeks of the new rule, it is uncertain how long such a policy can be maintained. If pressures result in financial failure, hospices in aforementioned rural areas may be forced to close, cutting off vital resources for terminally ill patients with fewer care options. Hospices may also opt to turn down admissions from “complex patients” with multiple conditions the provider cannot afford to address. Both long-term implications are dire, reducing patient choice and access.

Should hospices be forced to enact more stringent reviews of medication regimens upon admission, Dr. Robert Arnold, of the University of Pittsburgh Center for Bioethics and Health Law, says this policy puts providers in the position of “being the bad guy.” This practice would further common – and incorrect – beliefs about hospice services. “The problem, particularly for smaller hospices, is their complex patients with medications that are expensive,” Arnold says. “The patients are scared about stopping them for symbolic value, which is psychologically difficult, or they feel better when they are on those medications.” Such sentiments could stand in the way of a choice to opt for hospice support.

Arnold says this CMS effort places problems within our larger health system on hospice providers. “It feels unfair, because they weren’t involved in starting these medicines.”

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.


“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

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

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.”