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Quality of life at the end of life

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

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.”

4 Thoughts on “Under Obamacare, Hospice Providers Will Soon Have Incentive To Improve Quality”

  1. We need to make sure hospice patients can follow up with their doctors while in hospice and also have blood transfusions when needed, otherwise they feel abandoned and not cared for. They need to know that someone really cares about them at the end of their life. We need their doctors that are taking care of them, to be more involved and not just think well they are in hospice so I will peddle them off to another doctor that really isn’t informed as well as their regular doctor. That’s just plain crazy to treat a patient like that after the many years they have seen them and collected money from them and now they don’t want to care for them with compassion? It’s a crime and a very sad state of affairs.

  2. @ Trish, as a Hospice community educator I would like to point out that many times the persons attending isn’t abandoning the patient. The hospice is required to gather enough data to qualify the patient by a criteria format. As to the primary doctors involvement, at our hospice we always encourage the primary to be the attending doctor. Unfortunately many haven’t had the training or are comfortable with “comfort care and palliative treatments”. Which often utilize narcotics or treatments they are not as familiar with. Therefore, they ask that the Hospice Medical Director take charge of the care and treatment because they have been uniquely trained to treat and manage symptoms of a life limiting illness. Then there are MD’s whose busy practice prohibits them from being able to respond to a call from a hospice nurse in a timely manner and they know it. For us In hospice, every symptom is a potential for a less than desirable or worsening outcome for those we care for. We cant promise symptom/pain management and sit idly by waiting for a return call and so I repeat, some primary care doctors know this and elect for us to do the work and keep them informed. Our goal is always to help the patient NOT to have unwanted pain, or other symptoms and so a hospice Med. Director managing care may be a more logical choice. As to transfusions it is allowable for us to provide them for palliative or comfort care. However, we must keep in mind if this is in the patients best interest. Are we prolonging the dying process? Are we really improving the persons “quality” of life? Or, Is the patient even able to tolerate the treatment? There are some who can and some who can’t. We must also consider the outcome and potential side effects, or if there is a chance it will help or be like the boy who plugged the leak in the dam only to have something else occur that hastens the persons death which is not what we want or are about. We must always consider the patients wishes first. Such as; If the patient wants to have comfort and die peacefully are we acting in good faith by prolonging their life but not their “quality of life”? or prolonging the inevitable? You can see that there are allot of variables that enter into what we can do , must do and or explain why it may do more harm than good or be against their wishes or even not be clinically in the persons best interest.
    I am not sure what happened in your case regarding transfusions, but I understand your point of view. I am sorry that your hospice experience wasn’t as positive as we in hospice always hope for.

  3. I understand that hospice is paid by the insurance companies. Is That true? I thought that they were paid by the government.

    If a patient selects hospice and then decides to opt out of hospice services does hospice get paid by the insurance company as if the patient had died under the care of hospice?

  4. As a user of hospice (husband), I think it is wonderful, and I do think these records will help with quality AND save $$$. I can see that the extra record keeping is a burden, and it would certainly help the home visiting teams if they had laptop computers rather than having to make their notes by longhand.

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