Another Hospice Blog

In case you have not found it yet, the Hospice Foundation of America has started a Hospice and Caregiving Blog. There is some great content there for professionals and families; bookmark it.

How To Choose A Hospice: Why it Matters (updated)

This is the first in a multi part series on how to choose a hospice. The later posts will go into detail about what you need to know and how to find out, but before I get into all of that I wanted to talk about why it matters.

If you pump truth serum into most hospice workers they will tell you that there isn't much difference between their company and the others, and in reality there isn't. We all work under the rules of the Medicare Hospice Benefit. Medicare tells us what staff we must have, what we must pay for, who does and does not qualify for hospice, how often we can or can't do certain things, who we contract with to provide certain services, and even who we can't contract with. The Medicare Hospice Benefit rules hospice in the United States today. With that fact in mind, I'm going to tell you what I would want to know before choosing a hospice for a loved one.

I'm sure you are wondering why I'm writing multiple posts about how to pick a hospice if I start post number one by saying that most hospices are the same. The answer is simply: "Because the devil is in the details". If you call three different hospices and ask general questions about what they do and don't provide for their patients, you will hear almost the exact same thing three times. Does that mean that it doesn't matter which one you choose? NO! There are not many differences between hospice programs, but those little details that you don't even know to ask about could become a big deal for your loved one.

In all honesty, I believe that most hospices do a good job of taking care of the average patient. The differences come when dealing with the rare patient or rare situations. You never know which patient is going to be average and which will present something rare. I've seen quite a few hospice patients, and would not ever attempt to guess at which one is going to surprise me tomorrow. This whole set of posts is written just in case your loved one ends up having something happen that puts them in the rare category. If they do, you better hope you are with the right hospice.

The following posts will give you tips on what to find out about a hospice before signing up. Tip number one is that you need to find these things out before you sign up. Every time a hospice gets a phone call about a possible patient, things shift into hyper drive. Every hospice has protocol for exactly how that phone call is handled, and the person you end up talking to has almost always had some special training on how to handle these phone calls. At that moment, the person on the other end of the phone becomes a hospice salesperson. They want to take care of your loved one and will do what they can to get you to choose their hospice. To put this into perspective, in 2004, 44% of the hospices in America admitted less than 150 patients. That is less than three new patients per week. 16.4% had less than 50 Admissions, so if you are calling one of those agencies, odds are, you are the only possible admission they will have that week! It doesn't matter how good an agency is, if they don't have any patients to care for, they will not survive, so this phone call is very important to them.

As I stated earlier, hospices generally offer the same services. They are staffed and prepared to provide a certain amount of care to each patient. The person you are talking to on the phone knows exactly how far they can push that envelope to offer things that are above and beyond the norm. If you ask them for something that is beyond the company norm during that initial phone conversation, they might say yes. If you ask for that a month after you sign up, it will be much easier to tell you that hospice doesn't usually do that kind of thing. Once you have signed on and built relationships with the hospice staff, the hospice will assume that you are not going to leave for another hospice over something minor. If you ask for it before choosing a hospice, they know it could be a make or break detail. If you are going to sign yourself or a loved one up for hospice, make sure you ask your questions and get your promises up front. That first phone call is important, and most of the rest of this series is going to deal with things said during that one five minute call.

I have received criticism in the past because the above paragraph sounds cold and calculating. It makes it seem like hospice is "being sold like a used car". While I understand that criticism and know that the paragraph doesn't set well with many in the hospice world, I also know it is true. Don't get me wrong here, I am not saying that good hospices will withhold standard care for patients if they require more care as their illness progresses. I'm talking about special requests that push the boundaries of what a hospice is supposed to be doing for their patient. Every hospice administrator knows what I'm talking about here. Patients request things beyond the scope of normal hospice practice all the time, and hospices make a practice of providing things beyond the scope of normal hospice practice on a regular basis. The Medicare Hospice Benefit leaves many things in a gray area where nobody knows for sure what is hospice's responsibility and what is not. Every hospice has drawn their own line in the sand on what they believe they should or should not be responsible for providing to a patient. Here's an example I ran into recently. A bedbound patient's wife needed to leave town for three days and had arranged for the patient's elderly mother to stay in the home with the patient for those three days. The problem was that the patient was incontinent and his mother couldn't change him. We were asked if we would send an aide to the home to change him when needed (day or night) for that three day period. That type of 24 hour aide service isn't standard practice for a hospice patient. (The hospice is not the primary caregiver for its patients.) Could we do it for three days? Yes. Should we? There is no national consensus on that! My argument here is that if your request falls into this type of gray area, having a patient admission hanging in the balance may tip the scales toward the hospice agreeing to push the limits. Every hospice draws the line somewhere, but the odds of getting something in the gray zone approved is better at the time of admission than it is after the admission is complete. It's not selling used cars, it is just the reality that hospice, like any other business, must manage its scarce resources and can only push the envelope so far before going broke.

The next post in the series will start covering what you need to find out during that initial phone call.

How To Choose A Hospice - updated

Over the next few weeks I will be publishing an updated set of posts on how to choose a hospice. This is a series I posted first in March of 2005. The format will remain the same and much of the content will remain the same. My thoughts on some issues have changed over the past couple of years (I may have even been wrong about a few things.) and the industry has changed quite a bit. I think this series, out of all the rambling I have done, is probably the most important, so I wanted to try to keep the series updated to the current trends in hospice.

There are also many people reading this blog who didn't read it in 2005, and I hope you will all feel free to give your thoughts and advice in the comments section. Argue with me when you think I'm wrong; Lord knows many of you probably know more and have more experience in hospice than I do! Most people who need to choose a hospice don't even know what to ask. It is a HUGE decision that is often made quickly and with few facts. For those who do read these posts before making their decision, I want it to be as helpful as it can be. Post number one should be up soon.

If you think the price of gas is hurting you…

The price of gas has been making headlines for a while now, and has become a political football. There are all kinds of ideas being put out there by the President and those who want his job. We could have a gas tax holiday, drill for our own oil, punish the oil and gas companies, ride our bikes more… In the end I expect that our "leaders" in Washington will probably point their fingers at the other party and do absolutely nothing.

I'll stay out of the political side of the issue, and just say that if gas is going to cost $3.75 a gallon, Medicare needs to seriously consider giving rural hospices a little extra money. Every delivery you get these days has a "fuel surcharge", and hospices need to get into that game also. Rural hospices cover a lot of ground, and that is becoming very hard on their employees. Rural hospice nurses can easily drive 100 miles a day to visit four patients. Sure, the federal mileage reimbursement rate has gone up, but my gut says that the number of hospices that actually reimburse their employees at the full federal rate has not kept up.

The basic math here is that a $.10/mile increase to a hospice worker who averages 100 miles a day would cost the hospice $2,400 a year. Multiply that by the number of nurses, home health aides, chaplains, and social workers the hospice employs, and you've got a nice chunk of change.

The problem here is that every rural hospice administrator in the country has a huge battle going on in their head right now. We are in the middle of the most serious threat of a rate decrease in years, so this is not the time to spend more money. We need to be finding ways to decrease spending, so logic tells you that you can't increase the mileage reimbursement rate. On the other hand, if you don't help offset the massive increase in gas prices, then you risk losing good employees to jobs that don't require them to drive. Thus, logic tells you that you must increase the mileage reimbursement rate. Can you say "stuck between a rock and a hard place"?

Years ago Medicare gave Home Health a 5% rural modifier to offset these types of issues. It is time for hospice to see a rural modifier to help us keep our best employees in the field where they can do what they are so good at doing.

Medicare Officially Begins Hospice Rate Cut Attempt

(update: The link to the nhpco press release has been fixed. Sorry.)

I have focused quite a bit in the past on the proposed hospice rate cuts, and have probably done a poor job of explaining the different fronts on which this battle is taking place. One of those fronts has heated up quite a bit.

The Centers for Medicare and Medicaid Services has now officially proposed a rule change that will change the wage index that is used to figure hospice payment rates. This change, if it takes effect, will be phased in over a three year period and will reduce the daily rate that hospice can bill Medicare. The wage index is different for different portions of the country, so the exact effect for each hospice will vary. For my hospice, our rates will be reduced by exactly 5%. The fun part about this is that CMS can make the rule change without going to congress for approval. Thus, the fact that they have proposed the rule change is a big deal. I have no idea how many hoops the rule change has to go through before it takes effect, but, as far as I understand, none of those hoops will involve anyone outside of CMS in the decision.

NHPCO has written a very good press release about this, and has also been working to get congress to inform Secretary Leavitt that they oppose this rule change. You should read the press release. It does a good job of covering the reasons why this proposed rule change isn't a good idea.

The most important fact is that the rule change will reduce payment rates by 5% while a study done by MedPAC states that hospice profit margins average less than 3.5%. It would seem that the average elementary school child could understand that this math doesn't end up positive. Does Secretary Leavitt want hospices to reduce the type or amount of care they are providing to dying people? Do the math and draw your own conclusion.

My Hospice Cap Conclusion

I have been accused of many things in the comments section of my prior posts that mention the Medicare Hospice Cap issue. Most seem to be from people who are effected by the cap problem and think that I just can't understand the issue since I am not. Many were nice, many were not. To be honest, I have had trouble from day one knowing exactly what I think and feel about this issue. I'll try to sort that out for both you and I in this post.

I base my judgment on the following facts.

• My hospice does not have a cap problem.
  
• My hospice does not come anywhere close to having a cap problem.
  
• I have trouble picturing a way that my hospice would have a serious cap problem.
  
• I do understand how a hospice could have minor cap problems.
  
  • (Let me explain. The biggest thing that keeps my hospice from having cap problems is that we care for quite a few cancer patients who, on average, are not on hospice very long. This allows our dementia patients who, on average, live longer to have "room under the cap". If we stopped getting cancer patients, my hospice would probably be much closer to cap problems than we are now. Thus, I understand how, if your referral sources are exclusively working with the types of hospice patients that tend to live longer, you could find yourself in cap problems.
    
• I know there are hospices out there who have earned their cap problem, and I do not feel sorry for them in the least. Those hospices who admit people who have no business being on hospice, keep them on service for an extended period of time, and then whine about their cap problems get no sympathy from me. The thought of them going out of business makes me somewhat happy.
  
• I know there are hospices out there who have stumbled into cap problems, and I do feel sorry for them.
  
  • There is someone in my state that I look to as an example of what a hospice director should be. I believe this person to be honest with pure intentions, but this person's hospice has cap issues. Processing that is hard for me, and has helped me understand that good hospices can be caught up in the cap.
    
• There is no way to know for sure what percentage of the hospices with cap issues are problem hospices and what percentage are hospices with a problem.
  
• Most importantly, no matter what the people pushing for a fix to the cap seem to believe, there is no way to separate the cap issue from the other issues within the hospice industry.
  

With those things in mind, here are the conclusion I have come to. Am I right? I'm not sure. Will some think I'm wrong? No doubt. Will some think I am the devil himself? Probably. This is an emotionally charged issue to say the least.

My Conclusion:

I do not want congress to focus on changing the hospice cap. Instead, I want Medicare to focus more on enforcement of the cap.

My reasoning:

The government, especially Medicare, is well aware that there is abuse and corruption in the hospice industry, and they will be forced to address it at some point. As best I can tell, they have three opportunities on the horizon to address these problems.

1. The hospice reimbursement issues that are currently before congress. An across the board cut of hospice reimbursement has the ability to reduce the services hospice patients receive. Yes, if you cut the rates deeply, those companies that are only in hospice for the money will leave, but it will also force those who stay in the industry to reduce services to match the income. Even with that, the corruption will not be stopped. Any company that wants to bend the rules to increase profits would still be able to do so.
   
2. Later this year, Medicare will begin gathering information on exactly what hospices are doing for their patients. As much as they claim that they will not use this information for payment reasons, nobody believes them. I have said many times on this blog, the current Medicare Hospice reimbursement system does not work. It is crazy that we get paid the exact same amount for every patient no matter where they live, how sick they are, or what care we provide. I believe Medicare will change that in the next few years. I pray they will not use that fix as their way to try to fix every industry problem. We all know what happened to home health a few years ago. I think Medicare will change our payment system, but I hope the corruption within the industry will be under control so that Medicare doesn't have to "drop the hammer" like they did on home health. A lot of home health agencies went out of business when they changed the payment system and many of them were good agencies that got caught in the crossfire. It is in the best interest of hospices and their patients that the reimbursement system be set up to encourage and reward best practices instead of being set up to punish bad practices.
   
3. The Hospice Cap. Given the facts above, I believe that corrupt agencies are probably the ones who will be hit hardest by the cap. I also believe that is what the cap was created to do. There are going to be honest hospices who have cap issues, but I have trouble understanding how an honest hospice has a serious cap problem. Yes, they will have to pay back money. Yes, they are going to have to try to make sure they don't cross the cap line in the future, but, in the end, they will endure the pain and come out the other side alive and well. I believe that the hospices that owe amounts so large that they can't ever pay it all back are generally the ones that earned their problems. Some may have done this with good intentions of helping people (which is what they all claim), but the fact is that they admitted a lot of people who lived significantly longer than six months on hospice. They crossed the cap line at a dead sprint and kept going. The cap is a regulation put in place to keep hospice admissions reigned in around the six months to live mark, and it is doing its job. Enforcement of the cap will mean that patients are not admitted as early in their disease process as they have been in recent years, but it will not reduce the services they receive once they are admitted to hospice.
   

With those options in mind, I believe the best thing that could happen for the hospice industry as a whole is for the Medicare Hospice Cap to be enforced more not less. The best hope for those who will need hospice in the future is that the cap will be enforced and the bad actors will be put out of business. That will allow Medicare to focus on coming up with an appropriate payment system instead of a payment system intended to be punitive. Yes, this will cause some real issues for some hospices, but it will cause minimal issues for hospice patients. There is going to be pain in the hospice industry. I believe there should be some pain within the hospice industry, because there is, no doubt, corruption within the industry. Out of the three options listed above, enforcing the Cap is the best way to focus the pain towards corruption and away from patient care. Yes, some hospices will be injured in the crossfire, but I think the majority of those who should be allowed to survive will.

Pallimed’s Take on the Hospice Budget Cuts

As you know, I have been trying to raise some awareness about the hospice reimbursement cuts in the proposed federal budget. Christian at Pallimed has jumped on the bus with a post that is much more informative than anything I have written. Make sure and read his post to gain a solid understanding of what the issues are and then do something about it by contacting your congressman. Another good idea that Christian made is that you put in the comments of his post what you have done so that we can begin to see what effect the hospice blogosphere may be having.

(It doesn't hurt that Christian says a lot of nice things about me in his post. He is clearly a good judge of character, which must translate into a good judge of when it is time to start acting to keep these cuts from sneaking through congress.)

NHPCO Legislative Campaign

I've written a bit recently about the Medicare hospice payment changes proposed in the president's budget, and now NHPCO has a tool to help you let our legislators know about your feelings on this issue.

If you are like me, the effort you must go through to write your Senators or Representative a letter about any subject isn't worth the minuscule impact that the letter will have. Seriously, do you really think your senator is going to read your letter and change their mind based on what you say? Maybe I'm jaded, but I don't really think my elected officials really care what I think.

With that in mind, NHPCO has made it much easier to send a letter to the people you helped elect. Go to their Cap Wizard, click on " Help Protect the Hospice Reimbursement Rate", write your letter, put in your zip code, and magically your letter will be delivered to the right person. It is quick and easy, and as best I can tell, you don't have to be a member to use the tool.

While I don't believe that one letter makes a difference to our elected officials, I do believe that when they get enough mail on a subject they start to listen. So, pass this info on to everyone in your office. If every hospice worker in your area used the Cap Wizard, I'm almost positive your elected officials would get the message. The reality is that if this budget passes without the hospice portion being changed, the reduction in reimbursement will force hospices to change the way they operate. I believe hospice is awesome! We're not perfect, but cutting our rates by 15% is only going to hurt.

The Hospice Sky is Falling!

I can't believe I haven't written anything in a month! To make it even worse, it has probably been the busiest month in the industry since I started writing this a few years ago. While it seemed everything hit hyperdrive within the industry it also hit hyperdrive in my life. Wow.

It is almost midnight as I write this, so I'm not even going to attempt to give any type of detail to the things that have been going on. Thanks to all of you who have sent e-mails recently asking my opinion on subjects or making sure that I hadn't missed any of the big news. I've been keeping up with the news, but haven't been able to keep up with the writing.

The quick run-down of things that are happening in the hospice world:

• As I blogged recently, President Bush's budget calls for what will amount to a 15% reduction in hospice rates. I would love to know how many hospices turn a 15% profit. My guess would be that less than 5% of hospices in the nation turn that kind of profit, which means that almost every hospice in the nation would have to tighten their belts if not cut services. (If you have read this blog long enough, you'll know that I'm not a big fan of government spending, but a 15% rate cut will be very hard to swallow.)
• A congressman and senator from Oklahoma have introduced legislation to keep Medicare from collecting the hospice cap money. Currently some hospices owe Medicare quite a bit of money because they exceeded the "hospice cap" law. If they have to pay it back, it will put some of them out of business. How many? Nobody seems to know. Why do they owe money while the majority of hospices don't have any cap trouble at all? Good question. How in the world did these Oklahoma Congressmen become so convinced that Medicare shouldn't take their money back? I'd guess that hospices that owe money probably decided it was cheaper to get congress to bail them out than it would have been to pay the money back, but that's just a guess. (I'd love to write more about this one. Some other day I hope.)
• A lawsuit has been filed in Oklahoma dealing with the hospice cap issue. (I guess they thought it would be cheaper to hire a lobbyist and a lawyer than to pay the money back.) I really don't know much more than that. Both the congressional movement and the lawsuit can, I'm sure, be traced back to the National Alliance for Hospice Access.
• It is becoming more evident by the day that Medicare will release new hospice regulations ("Conditions of Participation") this summer. We won't know until then exactly what these new regulations are.
• Last but not least, two months from today hospices will be required to submit bills with much more information than we have ever submitted before. While some of the details have been ironed out, there are still some questions that have not been answered. The biggest question is how in the world Medicare expects us to track how many times the hospital nurse visited a hospice patient when the patient is in the hospital. Hospitals do not track each time an employee walks in and out of a room, but somehow Medicare expects hospices to magically be able to track and report that number. Hospices have tried to explain this to Medicare, but they don't really seem to care that we are expected to report something that we can't really know.

All of these subjects deserve their own post. Actually, may of them deserve many many posts. I write when I can. That brings me to yet another plea for others to join me in writing this blog. I am not the smartest guy in the hospice world. My opinions come from my perspective, but I know there are other valid opinions and perspectives. If you would like to write on any kind of regular basis (weekly or monthly), e-mail me and we'll talk more. Your identity will be kept anonymous just as mine has for all these years. There is a lot going on in the hospice world, why not help get the word out?

Hospice in the Federal Budget - revisited

I wrote a quick post earlier this month about the budget proposal that President Bush sent to congress. On first look, it was a little worse for the hospice industry than last year's proposal, but not a big deal. Well, your lowly hospice blogger missed something big in that post. Before telling you what I missed, I'd like to say that this is the precise reason that I encourage you to become a member of the National Hospice and Palliative Care Association. That little portion of the submitted budget that I overlooked is much more than a little issue, and I would have never known about my oversight if it weren't for the alert that NHPCO sent out to all of its members. More than that, when they sent out the alert they had excel spreadsheets already worked out so I would know just how much pain this budget could cause me. I'm sure I could have figured it out on my own, but there is little doubt that it would have taken me a few hours of research. Judging by the number of posts I have written for this blog lately, I'm pretty sure that I don't have a few hours to do that homework. The knowledge and time saved on this one issue has paid for my dues this year. (Not to mention all of the other things they do for me throughout the year!)

No, I don't work for NHPCO, and I do not benefit in any way if you are a member.

Moving on.

The detail I missed in the president's budget proposal is that he is proposing the end of the Hospice Wage Index. Instead of having a wage index just for hospices, we would start using the hospital wage index. Now, I'm no rocket scientist, but I'm figuring that a wage index is a wage index. In the long run, that is probably true, but in the short run, it is nowhere near true. The problem here is that there are differences between the two indexes. In my world, we get paid about 5% more using the hospice wage index than we would with the hospital wage index. That means, that if they make this change effective next year, we will not only not get a pay raise (see prior budget post) we will take around a 5% pay cut. That could really hurt.

It is a bit unclear to me but I believe that the president has proposed to phase this in over three years, which would make it easier to swallow. As I have said before, I'm all for appropriate payment rates, and if the hospital index works as well as or better than the hospice index, then I'm game. The problem is that I'm rather sure that there are a lot of hospices that are not prepared for a 5% pay cut. There are a lot of hospices that are working hard to break even, so taking 5% away may be a critical problem. Clearly, some of that is their problem and goes back to past discussions on this blog about the need for better business practices throughout the hospice industry.

The bottom line: I don't care who you are, if you lose 5% of your revenue, you are, at a minimum, going to have to tighten your belt. It would be nice to have three years to phase this in, but either way, every hospice in the nation needs to know that this is coming. You have now been warned.

Hospice Recommendations in President Bush's Budget

Excuse me if I'm not up in arms about the new budget proposed by President Bush. I thought about cutting and pasting my post from almost exactly 365 days ago here, because the proposal is largely the same.

When President Bush sent his proposed budget to congress, it called for a zero percent rate increase for hospice in 2009-2001. In 2012 & 2013 we would get our normal rate increase minus .65%. Now, going three years with rates not changing at all would be a big deal. I can promise my employees will be expecting pay raises in 2009, 2010, and 2011. Employee salary is often around 80% of a hospice's costs, so giving everyone a 3% "cost of living" raise three years in a row while our rates are not increasing would make a company that is currently making an 8% profit lose money. (Yes, that math is a bit fuzzy, but it is close enough.)


To understand the .65% portion, read the post from last year, because that was last year's proposal. Congress gets to make their changes before everything is all said and done, and I'm betting that the 0% increase goes away. Will they reduce our expected rate increase in some way? Only time will tell.


Just like last year, please don't give in to the hype that this is a rate cut. It is a cut in the amount of our expected pay raise. Seriously, read last year's post, click on some of the links. It ties the president's budget, Medicare payment issues, and our recent discussion of gaming together rather well. I guess Solomon was right when he said, "there is nothing new under the sun."

Tom Hoyer & the Hospice Cap

Briefly, I wanted to mention a section of the gaming portion of the article I've been writing about that I skipped. It is the section on the Medicare Hospice Cap. (My earlier posts on this article are here and here.)

Mr. Hoyer does not devote a lot of time to the cap, but what he says is priceless. First, let's review his credintials. He, as a CMS employee, was the person in charge of drafting the original hospice medicare regulations. If anyone on the face of the earth knows what the original purpose of the cap was, it is Tom Hoyer. With that in mind, we'll look at a couple of quotes.

"The cap was introduced by hospice's initial advocates as a guarantee that the hospice principle would not exceed the cost of conventional care. At present, it is the only effective check on abuse of the benefit..."

This chops the legs out of the argument that the cap is an antiquated law that was never meant to do what it is doing today. Apparently, the law was inserted by some wise hospice folk who knew that at some point people would try to "game the system".

Speaking of those arguing for a hospice cap change or moratorium, Mr. Hoyer says:

"There is a current movement to persuade the Congress to raise or eliminate the cap and it is being pursued by clever advocates with high-sounding arguments."

and

"The cynical effort to get legislative relief will likely fail. This is a case where the congress can do the right thing by doing nothing, a situation that plays to its classic strength."

I'll take him at his word that the push for Medicare Hospice Cap reform will fail, and that's fine with me.

As I said, he didn't devote a lot of time on the cap, but I sure think what he said is interesting in the light of everything we are being told by those fighing to change the cap.

Caring Article part II

I wrote a post about an article in Caring Magazine a couple of weeks ago, and want to continue working through the article today. (You should go back to post number one to understand what the article is about and who wrote it.)

As promised, today I want to discuss Mr. Hoyer's thoughts on the "gaming" that is currently going on in the Medicare Hospice world. First, none of these things are new to this blog. In fact, they are a big part of why I started this blog in the first place. There are hospices across the nation who are "gaming" the system, cherry picking patients, and focused on finding ways to increase profits while paying as little attention as possible to patient care. Gaming, as Mr. Hoyer calls it, is the basis of my argument that non-profit hospices are focusing on the wrong thing when they say that for-profit hospices are evil. For-profit hospices are not the problem. The gaming practices that are used by hospices, both profit and non-profit, are the cause of many of the issues in the industry. If we are going to fix the problems within the hospice industry, the subject of gaming must be faced head on. According to Mr. Hoyer, Medicare may do that for us.

In the article he identifies three different types of gaming that are real issues and that will, "evoke a strong response from the legislative or executive branches".

The first is what he titles "the Alzheimer's ploy". In this example of gaming, a hospice searches specifically for patients with long-term conditions like Alzheimer's or dementia and tries to get these people admitted to hospice as early as possible. Clearly, someone with Alzheimer's who is not in the final stages isn't all that expensive to care for, so finding as many of these patients as possible will really help your profit margins. He also rightly notes, "In its more shameful manifestations, it may mean subsequently re-determining the prognosis and discharging these patients before they show up as long-stay patients or need significant services." Just to make sure that everyone understands that last sentence, he is saying that some of the companies that focus on admitting patients very early on may discharge those patients from hospice before they get sick enough to actually need a lot of help or before they have been on hospice long enough to attract Medicare's attention. In either of those cases, you are clearly dealing with companies that are focused totally on money with no regard at all for the wellbeing of the patient. I don't really think there are very many companies that take their "gaming" to that extent, but I'm sure it does happen more than I want to believe.

The second "gaming" issue is "the continuing focus on recruiting nursing home patients". Mr. Hoyer rightly points out that hospice care in a nursing home is not a bad thing, and that there is evidence that it is good for the patient. Unfortunately, it seems that hospice in a nursing home is often better for the nursing home and the hospice than it is for the patient. I really can't say it better than Mr. Hoyer here:

"When hospices abuse this option, the result is a slight improvement in the lives of their nursing home patients, accompanied by an increase in revenue for both the nursing home and the hospice. In some cases, the agreements between hospices and nursing homes relating to these patients are reputed to include agreements in which hospices supply full-time staff to the nursing homes in return for a certain level of referrals. This is a practice that is likely to pique the interest of the Inspector General again, and may well lead to recommendations to reduce payments for patients in nursing homes, or even to eliminate the current option of caring for Medicaid patients who live in these facilities."

I can tell you that I have been approached by a nursing home administrator before with the proposition of, "if I give you X number of patients, will you guarantee me that you will keep an aide in the building eight hours a day Monday-Friday". That is exactly what Mr. Hoyer is talking about in the paragraph above, and I think it happens quite a bit. If a nursing home has enough patients on one hospice to keep the hospice's aide in the building for a full shift, then the nursing home can reduce their aide staff by one during that shift. Clearly, this kind of incentive is a win/win for the hospice and the nursing home. Clearly, it is also illegal. There is so much room for shady dealings between hospices and nursing homes that many hospices have lost sight of where the line even stands. This says nothing about the growing trend of nursing homes companies that start their own hospices. If you think it is easy for a hospice and nursing home to get a little too cozy, just think what they can do when they share ownership and management! The nursing home/hospice relationship is, in my mind, the biggest issue in the hospice world today and may well cause the entire industry quite a bit of pain in the not too distant future. That sure seems to be Mr. Hoyer's message.

The final type of gaming is what I have heard Don Schumacher of NHPCO call "drive by hospice". Mr. Hoyer calls it a "historical revival" since it is a problem that was identified not long before Medicare brought the hammer down on Home Health in the 1990s. Basically, the problem here is that there are quite a few new hospices that are being started across the nation for the sole reason that hospice is a profitable business that can be started with very little money or effort. Of course, if your desire to start a hospice is founded in the ease of entry into the industry and the lack of capital needed, then the much needed desire to care for sick people is missing from the equation. These companies are being started by people who often have no business being in the hospice business. Unfortunately, they see hospice as being just another business and treat it as such. According to the article, this was one of the things that caused the big crack down on Home Health and it was also one of the things that the crack down did a very good job of ending. I'm afraid that will be repeated in the hospice industry, and it will, no doubt, be painful.

That's the end of the gaming discussion and also the end of section one of the article. Before we move to section two, we'll talk about Mr. Hoyer's thoughts about the cap. Hopefully, I'll get to that next week.

Just Say Die

The awesome folks at Pallimed (if you are a hospice clinician and not reading this blog, then you are missing out on some great education and insight) pointed out a recent journal article advocating for the use of the word "die" when doctors talk to their terminally ill patients.

Good stuff.

Payment Change Discussion in Caring Article

The National Association for Home Care and Hospice puts out a very good magazine called Caring. As far as I can tell, it is not available on-line which is too bad, because the November edition had a great article titled "The Future of Hospice". The article was written by Tom Hoyer who worked for Medicare for thirty years and was "assigned to work on implementing the Medicare hospice benefit and was responsible for producing the regulations that have governed the benefit." He also "continued to maintain responsibility for hospice benefit policy…until his retirement." I guess that makes him very qualified to discuss the future of the Medicare hospice benefit from the Medicare prospective, which is what he does in the article. I really wish the full text was available online.

This is the first post in a series where I look at the many points made in the article. Much of what is written are topics I have written about in the past, but, for obvious reasons, seem much more real when Mr. Hoyer writes about them. The article is broken into two sections. The first discusses improvements that can be made to the Medicare hospice benefit. The second discusses changes in the "product" or changes in the core definition of hospice. This post deals with a portion of the section on improvements that can be made to the Medicare hospice benefit.

Payment Changes

This subject is one that I have discussed many times in many different ways. I believe that there is going to be a major change in how hospices get paid. I also believe that these changes are probably necessary. Mr. Hoyer seems to agree, but has some insight and details on how and when these changes will appear that I have not heard anyone say out loud before.

First, Mr. Hoyer points out that MedPAC and the GAO have been looking at this subject and have both concluded that, while the government is probably spending enough money on hospice, they are probably not spending it well. As he says, "They [MedPAC and GAO] believe the rates need to be reexamined with a view towards updating the components to reflect current medical practice, and to do a better job of matching individual payments to individual patients (case-mixed payment)." This means creating a system where a hospice is paid more for high need patients and less for low need patients. I have discussed here many times that there is a difference in the amount of care provided to home patients (higher need) as apposed to nursing home patients (lower need). There is also a difference in the amount of care (or cost of care) a dementia patient requires (low need) as opposed to an HIV/AIDS patient (high need). This new system would take those factors (and probably more) into account when determining how much a hospice is paid for each patient.

Mr. Hoyer's proof that this change is coming is the fact that the MedPAC and GAO reports called for data gathering to determine how to set up this new system. That data will start being gathered on January 1st from hospices who have voluntarily implemented the new billing system that becomes mandatory for all hospices later in 2008. Once enough data has been gathered, Medicare can start using the data to create a new payment system. The question is, why would they gather the data unless they planned to do something with it? The answer, they wouldn't. The good news for those, like me, who have been living in a bit of fear that the sky could fall on us at any moment, is that Mr. Hoyer says that this process is going to take some time. On that he says, "it is a safe assumption that payment reform would not likely occur until at least 2010, unless the Congress or the Administration make it a very high priority."

With this in mind, Mr. Hoyer's advice is for hospices to spend the next couple of years making sure that their operations will be financially sound in a case-mixed system. His hope is that the case-mixed system will stop the "gaming" being done by hospices that focus on recruiting low intensity patients to make profits.

"Gaming" becomes a big subject in the rest of section one. I'll talk about that more in the next post.

Merry Christmas

Luke 2

1In those days Caesar Augustus issued a decree that a census should be taken of the entire Roman world. 2(This was the first census that took place while Quirinius was governor of Syria.) 3And everyone went to his own town to register.

4So Joseph also went up from the town of Nazareth in Galilee to Judea, to Bethlehem the town of David, because he belonged to the house and line of David. 5He went there to register with Mary, who was pledged to be married to him and was expecting a child. 6While they were there, the time came for the baby to be born, 7and she gave birth to her firstborn, a son. She wrapped him in cloths and placed him in a manger, because there was no room for them in the inn.

8And there were shepherds living out in the fields nearby, keeping watch over their flocks at night. 9An angel of the Lord appeared to them, and the glory of the Lord shone around them, and they were terrified. 10But the angel said to them, "Do not be afraid. I bring you good news of great joy that will be for all the people. 11Today in the town of David a Savior has been born to you; he is Christ[a] the Lord. 12This will be a sign to you: You will find a baby wrapped in cloths and lying in a manger."

13Suddenly a great company of the heavenly host appeared with the angel, praising God and saying,
14"Glory to God in the highest, and on earth peace to men on whom his favor rests."

15When the angels had left them and gone into heaven, the shepherds said to one another, "Let's go to Bethlehem and see this thing that has happened, which the Lord has told us about."
16So they hurried off and found Mary and Joseph, and the baby, who was lying in the manger. 17When they had seen him, they spread the word concerning what had been told them about this child, 18and all who heard it were amazed at what the shepherds said to them. 19But Mary treasured up all these things and pondered them in her heart. 20The shepherds returned, glorifying and praising God for all the things they had heard and seen, which were just as they had been told.



New International Version
Copyright © 1973, 1978, 1984 by International Bible Society

Office of Inspector General Hospice/Nursing Home Report

The OIG released the first of two reports today looking at the differences between hospice care provided in nursing homes and hospice care provided somewhere else. (Thanks to NHPCO for pointing this report out to its members.)

The basic conclusion reads:

In our comparison of Medicare hospice beneficiaries who reside in nursing facilities to hospice beneficiaries who reside in other settings, we found that beneficiaries in nursing facilities tended to be older and more likely to have ill-defined conditions. Also, their time in care was longer and more costly. A second study will assess the appropriateness of payments for hospice care for beneficiaries in nursing facilities.

I hope "appropriateness of payments for hospice care" means they will assess the differences between the care provided to a home patient and a nursing home patient. If that is the case, I think the second report could change the hospice world. I have long said that, in general, nursing home patients are easier (cheaper) to care for than home patients. I have also advocated for a payment system that reflects this. In a game of follow the money, all you have to do is look to see how many of the large nursing home chains have started their own hospices to care for their patients. This is because nursing home patients take less effort and are therefore more profitable. We'll have to wait and see if this is really what the study is all about, but I sure hope it is.

NHPCO has also promised some reaction to part one of the study tomorrow. I'll post anything interesting when I can. My schedule will be a bit hectic with the holidays.

But the doctor certified them...

I really wanted to get off the subject of the Medicare Hospice Cap today, but I couldn't. There is one cap argument that I hear quite a bit that, while sounding fair and logical, fails to actually work. The argument in question is what I will term the "But the doctor certified them" argument.

As I said, this argument seems to make all the sense in the world, but I want to give two reason that it doesn't really hold up to scrutiny. Here's how it goes. Those fighting against the cap argue that every patient they have ever had on service was certified by their attending physician to meet the Medicare criteria of a six month life expectancy given normal disease progression. Who is the hospice to question the patient's attending physician? Seriously, where does the hospice nurse get the power to tell the doctor that the nurse's one time evaluation of the patient is more accurate than the opinion of the doctor who has been seeing the patient for years? If a patient's doctor believes that the patient meets the medical criteria for hospice, why would a hospice argue?

That's the "But the doctor certified them" argument, and it makes all the sense in the world. If a doctor certifies hospice appropriateness, then we shouldn't question them. Right? Wrong. Let me give you two reasons that it doesn't always work.

First, doctors are often too nice.

I know that the hospice community usually complains that doctors don't want to tell patients bad news and therefore wait too long to make a hospice referral. While that is often the case, there is a less frequent and less discussed flip side of that coin. This issue, which hospices don't complain about, is that often doctors will make hospice referrals because they know that hospice can help the patient. This referral usually comes after the family has brought the patient to the doctors office and told the doctor how hard it is to care for the patient. It is a long heartbreaking story from a tired and stressed family. The doctor vows to find them some help. Hospice is the help they find.

Many hospices have been paying marketing staff quite a bit of money to go convince doctors of the reality that there is nothing better than hospice care. If you have a patient living at home, hospice is the best care Medicare can provide for them. Some doctors have been listening to the marketers, so when they meet a hard case, they hand it over to hospice. Unfortunately, the doctor is thinking much more about the care that the patient needs than the patient's prognosis. They sign the hospice papers to get them care without really thinking about what they are signing. They are doing what they can to help a family. It is a noble thing to do, but it is still a patient who isn't actually appropriate for hospice.

Second, doctors get paid by hospices.

First, I'm not saying that something illegal is going on. This isn't some nefarious under the table bribe we're talking about here. Medicare requires every hospice to have at least one Medical Director. Everything I'm talking about here is done in the daylight, but it doesn't make it right.

Hospices hire Medical Directors to do the things they need a doctor to do. Many of them also hire Medical Directors with the hope that those Medical Directors will refer their patients to the hospice. This is clearly an area where the line between good and evil is gray at best. I know from what I would consider a reliable source that one hospice pays one of their Medical Directors $4,000 a month for the one meeting that he attends. That's $4,000 an hour. Do you think they expect "loyalty" from their medical director? No doubt! Do you think the Medical Director feels pressure to give enough patient to keep this gravy train coming? Probably. Could this lead the Medical Director to refer a few of his patients that he wouldn't otherwise refer? Possibly. (The Office of the Inspector General has noted these types of issues and, in theory, is going to be cracking down on it.)

Even if you follow the OIG's advice and pay a reasonable rate for the amount of work the Medical Director does, there is still a decent chance that the Medical Director is going to help you out. "Oh, Dr. Smith, census sure is down. If we don't get some patient's we may have to cut back." Could that line encourage Dr. Smith to certify someone that is just a bit on the gray line? No doubt.

Again, I'm not saying that hospices shouldn't have Medical Directors. They are an essential part of the hospice team. The fact that many hospices have one Medical Director for each team meeting they have (ie. a small hospice has team meeting weekly, so they have four Medical Directors that come once a month.) probably indicates that there is a benefit to having doctors on your payroll.

Conclusion

These are two examples of why doctor certification isn't always to be trusted. Is this the core of the cap problem? Not even close! My point here is that the argument that we should be trusting doctors to make certification decisions without any oversight or system abuse indicators just doesn't hold water. The patient's attending physician is, in my mind, the only logical person to certify hospice appropriateness, but that doesn't mean the system is perfect. Oversight is still necessary, and that was the point of the hospice cap from day one.

New York Times Hospice Cap Article

I don't have a lot of time today to comment on this article about the hospice cap issue in the New York Times. It quotes the NAHA group that has been a part of all the other press on this issue, but it also seems to have a bit more reporting to it than other articles on the subject. It does not manipulate patients as I have felt other articles have, so, on that front, it seems that while the discourse is moving to a national level it may be moderating its tone also. (At least that is my hope.)

The most interesting part to me is that, while I found out about the other articles from a couple of readers in Oklahoma or from NAHA's website, NHPCO was the one who sent a link to this one. The link was part of a set of somewhat vanilla talking points about the cap. There was no mention of NAHA in the talking points which further emphasizes to me that these two groups do not work together. Has NAHA woken the sleeping giant? What will the sleeping giant do once they are awake? We'll have to wait and see.

(Speaking of the readers in Oklahoma that have directed me to the press in their state about the cap, I'm guessing that this story is about to start getting a lot more coverage. If you see local newspapers or TV news about the cap (or hospice in general) send me the link and I'll post it to the blog. I think we'll all benefit by seeing what the different areas of the country publish.)

Oklahoma Cap Press Release

Below is a copy of a press release that was sent to me by someone in Oklahoma (whom specifically asked to remain anonymous). It is, if I understand correctly, a press release from the Oklahoma Hospice Association dealing with the news stories about the Medicare Hospice Cap. The person sending it to me included a note that said in part, "felt that you should know that not all hospices in Oklahoma share the philosophy of NAHA".

It is a strong response and deals with the issues that have bothered me in my last few posts on this subject. (Click on the image to read the press release.)

Hospice Cap Madness

I finally got a chance to check out the web site of the group that is producing all of this press about the Medicare Hospice Cap. They call themselves the National Alliance for Hospice Access, and their web site does a good job of making it seem like fighting against the Hospice Cap is a no brain decision. As usual, I think only half the story is being told, but they do a very good job of telling their half of the story. I might talk more about that later; this post is written to address an article that slipped past me until now.

There is a link to this article in the Daily Oklahoman on the NAHA website. The article really makes me mad. (Thus the title of this post.) I mean really, really, really makes me MAD! The article makes me more sure than ever in my thought that the television news story about the cap was done in bad faith. In my post on the TV news story, I said "it seems that the hospice is using, guilting, and upsetting patients to further its own political agenda. " At that point I gave them the benefit of the doubt.

Here are some excerpts from this article with my thoughts:

It wasn't until close to the end when I learned that the payment for our hospice care was capped, and independently owned hospices, like our extended family AutumnBridge, were suffering because of it.

How exactly did she find out that her father's cancer was causing a hardship for the hospice? Seriously, can you think of an appropriate way that this comes up in conversation? Why would any hospice share its financial problems with the family of its patients?

When Congress created the hospice benefit to cover end-of-life services, it also created two caps: a lifetime cap that limits each beneficiary to a maximum of 210 days of hospice care and a cap that limits the amount each hospice could bill Medicare in a single year.

The cap is about $20,000 per patient, and any payment in excess of that must be refunded to Medicare by the provider.

Dad was on hospice 290 days — 129 days past the number Medicare will cover for patients in Oklahoma County.

There are many factual problems with these paragraphs. The biggest being that the cap is not a per patient thing. If the average patient goes over the cap, then the provider must pay the money back. One patient going over the cap does not - I repeat - does not put the hospice over the cap. The hospice does not owe Medicare for the 129 days for this specific patient.

I assume, but do not know for sure, that either this hospice or NAHA saw/proofed/or approved this article before it was submitted to the newspaper. If that assumption is true, then they allowed flawed information to be published. At the very least, it seems they didn't do a very good job of explaining the cap to this family.

Now our hospice likely will owe close to $1 million to Medicare next year, partially because of my dad, and I can't help but feel some guilt.

The last line is the one that put me over the edge. We, as the hospice industry, have many different thoughts and feelings on the cap. I do not know how many members NAHA has. It could be a very large group; I don't know. I do know that not everyone agrees with NAHA. I know NHPCO has not come out supporting NAHA or publicly made any indication that they are planning to work with NAHA to help them achieve their goals. We, as the industry are divided over the cap.

I hope that we, as an industry, are not divided on the belief that making patients and their family feel guilty is a bad thing. This family has enough to deal with without being told that their father has caused the hospice, which the family loves and respects, has been damaged by their loved one living longer than medically expected. Even if there were a national consensus that the cap is a devastating issue, I would hope and pray that there would be a way to try to correct the problem without making patients and families feel guilty.

My Problem with the TV News Story

I posted here about a story on a local news channel about the Medicare Hospice Cap issue. In that post I said that something about having an actual hospice family interviewed made me a bit uneasy, but I "couldn't put my finger" on why. I've put my finger on it now.

A comment left on that post said:

I think using a real hospice patient makes this important story easier to understand and relate to at a personal level.

That's when my brain clicked on what was bothering me, the patient, or more specifically his wife, didn't seem to actually understand the hospice cap. Here's the offending part of the transcript as best I could transcribe it:


(narrator) - Al is just one example of a hospice patient that has lived longer than [the] time Medicare allows hospice funding.

(Al's wife) - It makes me angry. What do they expect him to do, just go behind the barn and go die?



There is no limit on the amount of time that Medicare will fund hospice for any individual patient. If you qualify for hospice for twenty years Medicare will pay for your hospice care for twenty years. Medicare puts a cap (thus the Medicare Hospice Cap) on the amount it will pay any given hospice company based on the number of new patients that hospice has admitted in that given year. There is no limit for how long Al can be on hospice. There should never come a day when Al is told that he needs to go out behind the barn and die because he no longer has access to hospice.

It seems to me this the patient/family doesn't really understand what is going on. I hope it is an editing problem that can be blamed on the television station, but, taken at face value, it seems that the hospice is using, guilting, and upsetting patients to further its own political agenda. If that is true, then we have seen a new low in an industry that used to stand for all that was good and noble in the health care.

More Press on the Medicare Hospice Cap

Apparently Oklahoma is the home of the Medicare Hospice Cap issue, or at least that is the place where the news media is paying attention. Again, thanks to a reader who sent a link to this local news report on the cap. (I have never linked to video, so I hope this works. Let me know if you have problems.)

Personally, I seem to find something distasteful about using an actual hospice patient in the story. I can't really put my finger on why though. Let me know what you think.

Hospice Cap Article

A friendly reader pointed out this article in the Daily Oklahoman newspaper about a hospice that is facing a huge cap issue.



Since it seems that most of the people interviewed for the article are from the hospice that has this large cap problem, it is a bit slanted to their point of view, but this does show the prominence that the cap issue is taking in the hospice world.



Here's a question for the mathematically inclined readers:

If this hospice owes $2,000,000 dollars in over payments, and that amount is equal to 20% of the hospices total reimbursement for the year, then what is the approximate average length of stay for patients on the hospice?



Yes, I know the cap formula is much more complicated than this, but I think we could use the information from the article to figure out roughly what the ALOS for the hospice was. Generally, I think you can assume that the cap allows an ALOS of 180 days. I think that means that the hospice featured in the article could well have an ALOS of around 220 days. Check my math; Lord knows that is far from my strong suit! Once you check your math, let me know if you think that a hospice that follows the certification/recert guidelines would/should/could have an ALOS of 220.



Before I publish this, I know commentors are going to say that cap problems can come from ethical hospices admitting patients that have been discharged by unethical hospices at the end of their cap usefulness. . . I know that kind of junk could happen, but I do not believe any of it has led to the apparent epidemic of cap issues. This hospice does not claim that their cap problems come from anything except, "their patients not dying fast enough."



While I'm at it, I'd also like to say that I find the accusation that Medicare is punishing a hospice because patients don't die fast enough to be tasteless. Rhetoric like that doesn't make me want to join the cap fight for sure!