‘Build on what is working,’ hospice leaders maintain
April 1, 2002
Build on what is working,’ hospice leaders maintain
Report calls for early consultations
In a recent survey conducted by the National Hospice and Palliative Care Organization (NHPCO) of Alexandria, VA, and Harris Interactive of Rochester, NY, nearly nine out of 10 Americans said they endorsed a consultation with end-of-life experts to inform patients with life-limiting illness of their care options. In a white paper that accompanied the survey, the authors called on lawmakers and providers to heed the results of the survey and begin providing new end-of-life consultations. The paper was written by Galen W. Miller, PhD, executive vice president of the NHPCO; J. Richard Williams, Jr., MD, executive vice president, VITAS Healthcare Corp in Miami; David J. English, DBA, president and chief executive officer of the Hospices of the National Capital Region in Washington, DC, and chair of NHPCO’s Public Policy Steering Committee; and Jonathan Keyserling, JD, vice president of public policy/communications for NHPCO. The paper also included an introduction written by former U.S. Sen. Robert Dole.
"For public policymakers, the agenda is clear," The authors wrote. "To improve end-of-life care in America we must build on what is already working. A broad-based public education effort to inform Americans about the resources available to them under the Medicare Hospice Benefit is urgently needed. Another equally important imperative is to change the medical education system to ensure that physicians and others who communicate end-of-life options to patients receive appropriate training."
Patients should receive early consultations’
Specifically, the paper cites "a series of early palliative care consultations, conducted by a Medicare-certified hospice team" as holding the greatest promise for improving end-of-life care as it stands in America. The paper says these consultations would ensure that a patient facing life-threatening disease, along with the patient’s physician and loved ones, would receive a timely introduction to the benefits of hospice and the expertise of the hospice team. Such consultations should include pain and symptom management, development of advance directives, a thorough exploration of treatment alternatives, and a patient-driven care plan.
"This simple but powerful concept can help overcome the barriers of ignorance and fear that trap dying patients and their loved ones in needless pain — physical, emotional and spiritual," wrote the authors. "Enactment of such an innovative proposal would help ensure that more Americans faced with a terminal illness understand and can gain access to the proven benefits of hospice."
From these early consultations could come a variety of recommendations that would help the patient and family cope with the difficult road ahead. For example, after the consultations, the patient could receive pain and symptom management advice from a hospice physician — advice that could be reimbursable under Medicare Part B. Although the full range of covered hospice benefits for social support and bereavement would not be available to the patient at that early stage, hospice team members could advise the patient and family on other possible sources of such support, such as hospitals’ departments of social work and pastoral care.
The hospice consulting team also could advise the patient and physician on when a re-evaluation for possible hospice eligibility would be appropriate, such as three months after a palliative care consultation.
Not a call for change in per diem
In 1999, a study done by actuarial firm Milliman & Robertson pointed out in glaring detail how Medicare Hospice Benefit reimbursement has largely remained the same since its inception two decades ago, while the manner in which hospice care is provided has changed drastically. The end result, the report showed, is that the amount Medicare pays for hospice care is often not enough to cover the cost of care over a patient’s entire length of service.
The study compared cost data from 1982, when the Medicare hospice benefit was first established, with cost figures from 1998-1999. The study pointed out a number of areas in which Medicare has failed to keep up with hospice costs:
• Patients are enrolling in hospices later. With patients electing the hospice benefit closer to the time of death, there is less revenue opportunity for hospices. According to the study, the average length of service has dropped to 40 days, while the original Medicare hospice benefit set the original rate based on a 70-day length of service.
• Hospices are using new technology. Advances in technology, breakthrough therapies, and prescription drugs have increased the cost of hospice care far beyond Medicare’s annual market basket update, which is used to determine annual reimbursement increases. For example, in 1982, prescription drug costs amounted to about $1 of the $41.46 per diem payment. Twenty years later, prescription drug costs have soared 1,500% to account for $16 of a per diem rate that has only slightly more than doubled to $98.96.
• There has been an increase in outpatient hospital therapies. The advent of palliative care chemotherapy and radiation treatment increased cost per day to more than $17 per day. Medicare originally expected outpatient therapies to account for about $3 of the per diem reimbursement.
"The [NHPCO survey] is not saying there needs to be more reimbursement," Keyserling says. "What it does say is that hospice has been providing excellent care for the past 20 years, and more people should be made aware that it is available to them. We want to see an increased knowledge about hospice, which hopefully will lead to more timely admissions."
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