FI seeks consensus on non-cancer policies
Hospices in other states continue to seek solutions
While concerns continue to run high among hospices nationally about the implementation of local medical review policies (LMRPs) based on National Hospice Organization (NHO) "Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases" (see related story in Hospice Management Advisor, April 1998, pp. 47-49), one fiscal intermediary (FI) is trying to work collaboratively with hospices in its region to make the policies more workable.
Blue Cross of California in Woodland Hills, which processes hospice claims for five Western states, has convened a Hospice Policy/ Docu men tation Task Force with representatives from the Arizona, California, Nevada, and Washington hospice organizations, among others. The first meeting was held March 26, and the task force will be reviewing eligibility policies for eight non-cancer diagnoses, one disease at a time.
Creating 'user-friendly' LMRPs
In a presentation at the California State Hospice Association (CSHA) annual meeting held in Sacramento in March, Blue Cross' Ellen Allen, RN, MS, explained, "We've always had LMRPs, which typically are developed in the absence of a national law, to clarify and provide specific detail as a basis for medical review decisions made by our medical review staff. . . . We took these [non-cancer] policies, looked at them, and said, 'Let's see what the providers say.'" Draft policies sent to all hospices on Blue Cross' roster last fall generated considerable response.
"The issue is clear. It isn't that we aren't going to write these, because we've been mandated to write LMRPs in this area. There will be LMRPs. But we want them to be as user-friendly as possible. We hear the concerns about the restrictive language in the initial policies," Allen said. "We have chosen to have a representative group of providers meet with us. . . . We really want LMRPs that will help us make consistent and fair decisions in medical review. In order to do that, we need documentation that helps us do that."
Meanwhile, hospices in other states continue to gather data showing that many patients enrolled on hospice care and dying within six months would not have qualified under the LMRPs. Walter Forman, MD, president of the American Academy of Hospice and Palliative Medicine, is said to have written a letter to Health Care Financing Admini stration (HCFA) administrator Nancy-Ann Min DeParle requesting that the policies be discarded.
In April, a group of providers, along with NHO chair David A. Simpson, MA, LSW, and president Karen A. Davie, met with Harry Feliciano, MD, MPH, medical director for Palmetto Government Benefits Associates, the Columbia, SC-based FI for hospices in 12 states. At that meeting, NHO urged suspending implementation of the LMRPs for focused medical review until more testing could be done, and to work on the issues with Palmetto's recently instituted regional Interme diary Advisory Committee. Providers report one positive development from this meeting: Palmetto was able to see national hospice leadership backing their concerns. However, the FI still is going forward with using the LMRPs.
Brad Stuart, MD, hospice medical director for VNA and Home Hospice of Northern California in Emeryville, lead author of NHO's original guidelines, tells HMA that he participated in a teleconference with FI medical directors in March, aimed at defusing providers' fears about the policies. Stuart indicates that the policies will be used both for focused medical review and for a HCFA corrective action plan study. In either case, hospices could receive additional development requests for more information before their claim would be processed.
Accurate prognosticators may be out of reach
HCFA also has emphasized that hospices still can obtain coverage for patients who don't meet the requirements if they document either significant comorbidities or physical evidence of rapid decline, such as decreases in activities of daily living, functional status, or weight, Stuart says.
"I'm cautiously optimistic that we'll find something that works," he says, adding that it's still too soon to say how the policies will be applied to hospices in actual practice. Ultimately, however, "we may never come up with a simple set of easily applicable guidelines that are sensitive enough to include all patients who will die within six months, yet specific enough to screen out those who are not terminally ill." Based on prognostic data from SUPPORT (Study to Understand Prognoses and Preferences from Opportunities and Risks of Treatment) and his conversations with SUPPORT co-principal investigator Joanne Lynn, MD, Stuart concludes it may not be possible to develop scientifically accurate prognosticators for patients dying of diseases other than cancer.
"That opens up a whole new set of issues for hospices about how to do end-of-life patient selection for diseases such as CHF, where good palliative treatment is the same as active or life-prolonging treatment," he adds. "It will require big-time policy changes for hospice. You're no longer talking about terminal care or even palliative care, but end-of-life care, and hospice will be left out in the cold unless we can come up with a broader definition for this kind of care."
A recent survey of doctors' attitudes and practices regarding physician-assisted suicide and euthanasia reveal that while the practice is rare, many more physicians would participate if it became legal. Surveys were mailed in 1996 to over 3,000 physicians in ten specialties most involved in the care of dying patients, and 61% responded.
Fully one-fifth of respondents had been asked by their patients for assistance in dying, but only 6.4% said they had ever carried through with a request to hasten death, either by lethal prescription or lethal injection. These numbers would jump dramatically if legal prohibitions were removed; 36% say they would prescribe lethal medications and 24% would give lethal injections.
The doctors' written responses to the survey also noted their discomfort in trying to distinguish between giving medications to dying patients for the relief of terminal suffering and lethal injections for the purpose of hastening death.
Source: Meier DE, Emmons C, Wallenstein S, et al. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 338(17):1,193-1,201.
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