Concurrent care makes good business sense
Facilitating provision of full hospice care
Twenty years ago, hospices broke into the Medicare market with the Hospice Medicare benefit, a bold move by many hospices to elect a per diem payment for care of a patient whose cost of care could exceed the total of per diem payments.
Some 15 years later, payers suggested something similar to physicians. They called it capitation, but most doctors found the risk too much to stomach. Hospices in the early 1980s were pioneers in taking on risk, a fact that often is overlooked these days.
Nevertheless, the industry’s foray into risk transformed the hospice industry from a collection of small volunteer organizations to a sector that takes in nearly $4 billion annually from Medicare. Once again, however, hospice must consider another risky proposition.
For years, hospices have been saying they needed earlier access to patients with terminal illness to provide the full benefit of hospice care and to succeed financially. Experts suggested modifying the terminal illness certification to allow earlier referrals and perhaps revamping how hospices are reimbursed.
Combine hospice care with curative efforts
While these may be things that should be done, hospices should consider taking the same kind of bold steps they took 20 years ago to advance the practice of combining hospice care with curative efforts.
Why, you may ask? Because it makes good business sense, and it improves the quality of care at the end of life, says Ira Byock, MD, director of Promoting Excellence, a national program office of The Robert Wood Johnson Foundation, and director of The Palliative Care Service in Missoula, MT.
Surveys and anecdotal research have shown that patients and their families generally agree with the principle of hospice care, but they shunned hospice until it was too late to reap the full benefit of hospice care because they didn’t want to give up the care they were already receiving.
If hospices were to take this customer information to heart, they would realize that many potential hospice patients are lost because hospices were unable to offer a product that suits the customer.
"Hospice needs to expand its service products," says Byock. What he means is that if consumers are asking end-of-life care providers — which means hospices or any other organizations providing that care — to provide palliative care sooner in the disease process without requiring patients to give up the care they are already receiving, then hospices must find a way to offer that product.
"We need to ask ourselves if we are going to provide these services," Byock adds. "If we don’t do it, someone else will."
Finding a partner
Under today’s current reimbursement rules and regulations, hospices cannot be reimbursed for care that falls outside the terminal illness certification. Larger hospices that have the resources to underwrite the cost of care that is not reimbursed may be able to offer palliative care services to patients who have yet to qualify for the benefit.
This requires finding a partner in the community — which is easier said than done. Most hospitals and physicians don’t want to be bothered with proposals to partner with a hospice. Byock advises going further up the health care food chain to insurers or any other organizations that bear the financial risk of underwriting the cost of health care. Among the list of potential partners are:
- the dominant private insurer within a market or region;
- a safety net health system, such as a rural health system;
- globally budgeted health systems.
A 2002 report issued by Promoting Excellence cited a project involving the Department of Veteran’s Affairs (VA), which operates a safety net system that provides health care to veterans of all military branches.
The VA Greater Los Angeles Health Care System implemented a palliative care model with disease-condition-specific elements for poor-prognosis veterans with lung cancer, congestive heart failue, and chronic obstructive pulmonary disease. The program centered around a nurse case manager who educated enrolled patients and families regarding decision-making and symptom self-management, provided continuity and coordination of care, and served as the hub of an interdisciplinary palliative care team that helped manage patients’ psychosocial and spiritual needs.
The program introduced palliative care soon after diagnosis, worked closely with hospices and other home-based services, and eased the transition into hospice care. In the final month of their lives, Pathways of Caring patients had total health care costs of $10,248, compared with $18,853 for a retrospectively matched control group, with most of the savings resulting from reduced hospital costs.
Assuming that evidence of improved access, improved quality of care, and greater financial efficiency is borne out in similar studies conducted by entrepreneurial hospices, hospices that implement this model of care would not only have satisfied patients’ request for combined hospice and medical care, but payers’ demand for the same.
Don’t forget anti-kickback laws
In all the excitement to bring a promising hospice model to market, hospices must remember that unless Medicare relaxes the rules as part of a demonstration project, any partnership must follow Medicare’s rules and regulations. If a hospice has an agreement with another health care provider, such as a physician group, to provide palliative care to non-hospice patients, it must navigate anti-kickback laws.
An Office of Inspector General (OIG) advisory to a Florida hospice in 1999 offers some guidance in this area. In the advisory, which applies specifically to the hospice that sought OIG’s guidance, the OIG said the hospice could provide free services as long as it was not doing so in exchange for future referrals and as long as it made the distinction between the free services it provided to its non-hospice patients and the core services it provided to hospice patients, such as labeling the free services as a community service that is nonexclusive to the physician practice.
Based on the 1999 OIG advisory, palliative care-related services a hospice could provide without reimbursement to non-hospice patients include:
- friendship and visitation;
- transportation;
- assistance with writing and reading correspondence;
- running errands;
- food preparation;
- respite care for the family or caregiver.
The other option is to devise a demonstration program that sets aside pesky rules and regulations in order to investigate promising ways to deliver publicly funded health care.
Twenty years ago, hospices broke into the Medicare market with the Hospice Medicare benefit, a bold move by many hospices to elect a per diem payment for care of a patient whose cost of care could exceed the total of per diem payments. Today hospice must consider another risky proposition.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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