Hospice Group Concerned About Proposal for More
Restrictive Medicare Payment Rules
Medicare Payment Advisory Commission (MedPAC)
objects to how hospice payments determined
March 2, 2009 – The National Hospice and Palliative
Care Organization (NHPCO) cautions that changes in the way Medicare pays
for hospice services, as recommended Friday by the Medicare Payment
Advisory Commission (MedPAC), are “dramatic changes to the hospice
benefit from established patterns of reimbursement” and “are sure to
produce displacements and unintended negative consequences.”
Report to Congress again emphasizes Medicare’s
payment system for private fee-for-service plans is seriously flawed;
wants significant cuts to home healthcare providers (payments cuts of
5.5% next year), hospice end-of-life care, medical imaging services and
Medicare Advantage insurance plans; does suggest a 1.1 percent hike for
doctors but more transparency.
MedPAC’s Fact Sheet released with the report to
Congress said, “The hospice benefit provides a substantial contribution
to end-of-life care for Medicare beneficiaries. However, MedPAC research
finds that Medicare’s hospice payment system contains incentives that
make very long stays in hospice profitable for the provider, which may
have led to inappropriate utilization of the benefit among some
hospices.
“We also find that certain hospices have
questionable practice patterns (e.g., very long stays, financial
relationships with nursing homes) that justify additional oversight.
Finally, we find that the Medicare program lacks data vital to the
effective management of the benefit.”
This was followed by four recommendations:
• The Congress should direct the Secretary to
change the Medicare payment system for hospice to: have relatively
higher payments per day at the beginning of the episode and relatively
lower payments per day as the length of the episode increases; include a
relatively higher payment for the costs associated with patient death at
the end of the episode; and implement the payment system changes in
2013, with a brief transitional period. These payment system changes
should be implemented in a budget neutral manner in the first year.
• The Congress should direct the Secretary to:
require that a hospice physician or advanced practice nurse visit the
patient to determine continued eligibility prior to the 180th-day
recertification and each subsequent recertification and attest that such
visits took place, require that certifications and recertifications
include a brief narrative describing the clinical basis for the
patient’s prognosis, and require that all stays in excess of 180 days be
medically reviewed for hospices for which stays exceeding 180 days make
up 40 percent or more of their total cases.
• The Secretary should direct the Office of
Inspector General to investigate: the prevalence of financial
relationships between hospices and long-term care facilities such as
nursing facilities and assisted living facilities that may represent a
conflict of interest and influence admissions to hospice, differences in
patterns of nursing home referrals to hospice, the appropriateness of
enrollment practices for hospices with unusual utilization patterns
(e.g., high frequency of very long stays, very short stays, or
enrollment of patients discharged from other hospices), and the
appropriateness of hospice marketing materials and other admissions
practices and potential correlations between length of stay and
deficiencies in marketing or admissions practices.
• The Secretary should collect additional data on
hospice care and improve the quality of all data collected to facilitate
the management of the hospice benefit. Additional data could be
collected from claims as a condition of payment and from hospice cost
reports.
The following is from the news release issued by
the NHPCO:
Each year, more than 1.4 million patients and
family caregivers seek hospice care. The Medicare hospice benefit is
responsible for millions of people living as fully as possible until the
end of life.
The hospice community is dedicated to not only
preserving the benefit, but enhancing it so that hospice is able to
continue to appropriately serve the unique and changing needs of dying
Americans. Hospice and palliative care providers, through the support
that comes from Medicare, are recognized as the leading providers of the
interdisciplinary, holistic care considered to be the “gold standard” of
end-of-life care.
Hospice care is also cost-effective. As was
reported in a 2007 Duke University study, hospice reduced Medicare costs
by an average of $2,300 per patient, amounting to a $2 billion savings
in a single year.
Statement on MedPAC’s Recommendations for Hospice
Reform:
Over the past several years, MedPAC has undertaken
a review of the Medicare hospice benefit. While specific reforms and
enhanced accountability measures are laudable and should be encouraged,
those changes should be framed in the context of a comprehensive review
of the various and complex components of end-of-life care, and how the
continuum of care can be expanded to increase access for patients and
families. Included in this comprehensive review of hospice should be
payment methodologies, fiscal constraints review, alternative
eligibility criteria, testing of new models of care, as well as any
number of other issues. The hospice community is committed to work
toward these goals.
Guiding this review ought to be several clear
principles. Among them are:
● Advancing hospice and palliative care programs
as the recognized providers of end-of-life care;
● Preserving and enhancing the Medicare hospice
benefit;
● Recognizing “high quality” as the standard to
which all providers must subscribe;
● Ensuring accountability through transparency
and fair regulatory scrutiny; and
● Promoting increased access through expansion
and collaboration.
Payment policy is one of the areas of the Medicare
hospice benefit that needs to stay current, so that payment
appropriately recognizes changes on patient demographics and treatment
protocols. Updates should be carefully considered and evidence-based to
ensure that behavioral consequences are understood prior to
implementation.
The present payment methodology has served the
hospice community and the public well since its inception, virtually
without change. Analysis of both current and historical patient level
data is necessary to fully understand and predict future behavior and
needs, and make changes that continue to provide benefits to patients
and to the Medicare system.
As with any payment system, dramatic changes to the
hospice benefit from established patterns of reimbursement are sure to
produce displacements and unintended negative consequences.
Given the nature of hospice referrals and the
unique characteristics of the end-of-life patient demographics,
unintended consequences of such changes are inherently difficult to
predict. Any number of issues might warrant attention, but effectively
quantifying such items in terms of behavior changes of patients and
providers would be difficult. Payment reforms should be incremental,
based on adequate data analysis, and need to be undertaken carefully,
with effects on the patient and family in mind.
The hospice community applauds the open and
informed process that MedPAC undertook to produce the recommendations,
and looks forward to working with the Commission, appropriate oversight
agencies, and Congress to ensure that the Medicare hospice benefit
continues to serve patients at the end of life in the compassionate and
high-quality manner that they deserve and expect.
Keep up with the latest news for senior citizens, baby
boomers
March 2, 2009 – The National Hospice and Palliative
Care Organization (NHPCO) cautions that changes in the way Medicare pays
for hospice services, as recommended Friday by the Medicare Payment
Advisory Commission (MedPAC), are “dramatic changes to the hospice
benefit from established patterns of reimbursement” and “are sure to
produce displacements and unintended negative consequences.”
