Conditions of Participation Reaction to Date

Clearly I am nowhere near finished digesting the 757 pages of the final Medicare Hospice Conditions of Participation, but, since I have read until my eyes can't take it any longer, I figured I'd give you my first impression. I reserve the right to change my mind, but, at this point, I'm impressed with what Medicare has done.

Shockingly, I believe Medicare has done a good job here. Perfect? Of course not. Good? Yes. What has impressed me is the thoughtfulness Medicare has shown in dealing with the comments submitted by people within the industry when they published the proposed rules a few years ago. Over 400 of the 757 pages deal with comments made during that period and Medicare's reaction to them. From what I have read so far, Medicare listened to and understood the concerns of the hospice industry and made the changes necessary to make the regulations better. There are still some parts that are unclear to me, but that's just part of working with the government.

I'm sure I will find quite a few details that I'm none too thrilled about, but overall, it seems that these new regulations may have succeeded in making the Medicare Hospice Benefit better.

Conditions of Participation Link

Here is a link to the .pdf of the new Medicare Hospice Conditions of Participation. I've gotten to page three of 757, so no great insight from me. The thing I was scanning for was the implementation information, and I was very happily surprised when I found it. Most were expecting a sixty day implementation period and hoping for ninety. We got 180! That gives us six months to figure out what the other 754 pages say and how to deal with them in our hospice programs. That is a relief.

New COP's are Published!!!

One of my first posts on this blog was about my dreams and requests for the upcoming changes in the Medicare Hospice Conditions of Participation. Well, a few years have gone by, and I'm finally going to get to see if my dreams have come true.

According to NHPCO, the newly revised final COP's have been posted at the Federal Register. They are not available on the internet yet, but should be tomorrow. Of course, the document is 800 pages, so it may take some time to sort through. We should know most of what is in them, but there are still a lot of people who are holding their breath hoping there are no surprises.

This is a huge moment in the history of hospice in America, but it is going to take us a few weeks to actually understand what happened today.

How To Choose a Hospice: Why Management Matters (updated)

(This post is part of a series of posts. To read from the begining of the series go here.)

Part three is an easy follow up question to the one you asked in part 2. Now that you know who owns the company, you need to know how many offices they have, where the offices are, and which one is the home office. You now need to know if the "big cheese" works out of your local office. (I use "big cheese" because this could be different people with different titles for different hospices. If the owner actually works for the company, then clearly the owner is the big cheese. The big cheese's desk is the place where the buck stops. You need to know who the big cheese is and where he/she works.

You need to understand three things to understand why this question is important.

1. First, most states limit how much territory any one office can cover. My hospice is allowed to admit any patient that lives within 50 miles of the office in any direction. If it is 51 miles to your house, I can't help you. To expand the area a hospice can cover all you have to do is open a branch office. Each office has its own 50 mile radius, so by opening a branch 49 miles from the home office you can serve patients 99 miles from the home office. If possible, you want to work with the big cheese's office. The nurses at that office have direct access to the person who makes the decisions. Branch offices rarely have any employees who make business or financial decisions. Those offices are staffed with clinical employees who must call the home office to get answers to business related questions, which leads to the second thing you must understand.
   
2. It is easier to be mean or heartless over the phone than it is face to face. If a nurse walks into the big cheese's office and asks for something that is good for the patient but bad for the checkbook and the big cheese tells her no, then the big cheese will have to look her in the eye every day knowing that she thinks he's a greedy heartless SOB. If the nurse calls from an office that the big cheese almost never visits and asks the question, then he doesn't have to worry as much about dirty looks or the lost respect of a coworker. The more detached the big cheese is from the patient, the easier it is for the big cheese to lose perspective of what is important. I meet many of the patients from our home office, but would rarely meet a patient from a branch office.
   
3. Third, you must remember that the cream rises to the top. The top is always at the home office. The head nurse at the home office is the boss of the head nurse at the branch office. As a nurse gains experience they are naturally going to gravitate toward the home office. I'm sure there are exceptions to this rule but generally the home office is going to have better staff than the branch office. If you are choosing between two hospices and one is a home office and the other is a branch, choose the home office.
   

Remember, our goal here is to choose a hospice that will do everything possible for the hardest of patients. With that in mind, do you think it is in your best interest to work with a hospice where the big cheese is detached from or ignorant of the issues your loved one is dealing with? I didn't think so.

All right, I promise that I'll get off my anti-corporate hospice bandwagon for the next post where I'll discussion location, location, location.

How to Choose a Hospice – Why Ownership Matters - updated

(This post is part of a series of posts. To read from the begining of the series go here.)

As I said in the previous post, the differences between hospice companies are often small and usually hard to find. This post deals with one thing that I feel is a huge difference; Ownership.

Who owns the hospice is a very important question, because it gets to the very core of the reason the company exists. If a company is listed on the stock exchange, then the stockholders are the owners. Do you think they invested in the company because they wanted to own the stock of a company that takes good care of people? Do you think Charles Schwab advises their clients to invest in HCR Manor Care (the owner of the national chain Heartland Hospice) because they treat people right? No, investors buy stock because the company makes money. If the owners of the company are focused on profit, then those that run the company must make money or else. Do you think the CEO of Heartland Hospice or, the largest hospice in the nation, VITAS (owned by Chemed who also owns Roto-Rooter) is more likely to lose his job because of poor patient care or poor earnings? In that situation, patient care can not be the number one priority. Your priority is your loved one; if that isn't their priority, then there could be problems. Avoid the problem by finding out who the owner is and what their background is. Some of this information can be found on the company's website if you want to do that research to avoid wasting time with a phone call.

Many hospices are non-profit, so they may say something like, "We are owned by our community". The community won't be expecting profits from the company, so your free to move to the next question. I'm not saying that non-profits are always your best choice, but they do avoid the ownership profit-margin issues that can come with some for-profit hospices.

A follow-up question here would be to find out what else the company owns. Two years ago, I would have told you that a hospice that does anything other than hospice is a warning sign that you may not be working with the best. Now, many hospices are diversifying into other areas of healthcare because of instability within the hospice industry. They are branching out to solidify their bottom line just in case the government makes changes to the Medicare Hospice Benefit that negatively effect hospices financially. I guess that means that my advice here is to find out what they did first. If they do home health and hospice, odds are they did home health before they did hospice. This means that hospice isn't their core business or mission, they branched out to hospice for the same reasons hospices are branching out to other health care businesses today. The problem in this type of situation is that these companies generally will view hospice as the equivalent of home health and treat hospice the same way they treat their home health. You want a hospice that exists to do hospice. It is crucial that your hospice see hospice care as something sacred. They will all tell you that they do, but knowing their ownership background will help you know which ones to believe. A hospice that has branched out into other areas of health care may be just fine, but companies that branched out into hospice may be a red flag.

That's question number one. I'll post on question number two in another post.

A special note for those of you choosing a hospice for someone in a nursing home:
Do not use a hospice that is owned by your nursing home. Let me repeat. Do not use a hospice that is owned by your nursing home. Odds are the nursing home has told you that you should consider hospice and in the same breath told you that you should consider a specific hospice. If the hospice they recommend is owned by the nursing home or by the same person/company who owns the nursing home, stay away! I can not stress this enough. The biggest service a hospice provides for nursing home residents is a different set of eyes and ears for the patient. A hospice that is not affiliated with your nursing home will not have any problem reporting a problem if they see one. Their focus is making sure that the patient is cared for, and if they have to point out poor care that is being given by the nursing home, then so be it. If the hospice and nursing home are in bed together, then the hospice employee knows that they are making their boss look bad when talking to families about issues related to the nursing home. Worse than that, many nursing home/hospice combo companies have some crossover employees. If the nursing home nurse changes her nametag during the day and becomes the hospice nurse, do you really think she will do much in the way of assessing the patient? She saw the patient earlier in the day as his/her nursing home nurse, so why pay attention later just because she has a different name tag on? One more time: do not use a hospice that has the same owner as the nursing home. Every nursing home patient needs someone who is willing to rock the boat. Hospice workers are often professional boat rockers; don't reduce the impact that hospice can have on your loved one by using a hospice that can't speak freely when there is a problem.

For the sake of clarity here, I am not saying that hospices that are owned by nursing home companies are not good at what they do. Some of them may be excellent, but there is an inherent conflict that comes from them caring for patients in their own facilities.

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.