Plummeting length of stay problem continues to challenge hospices
Answer may lie in accepting the new per diem reality
In the eight months since Hospice Management Advisor last devoted a cover story to the problem of plummeting length of stay and crisis admissions, the problem seems to have gotten worse. For some providers, the downward trend may have bottomed out. But the basic reality of operating under a per diem payment mechanism remains. Hospices encounter higher costs and intensity of services during the patient’s first few days after enrollment to introduce the program and then again during the final days to manage the patient’s active dying with a major financial and administrative headache when these high-cost periods overlap.
But while some hospices continue to study the problem, seek the causes, and attack them through more intensive education for physicians and consumers, others are coming to view it as a permanent reality in the health care system of the late 1990s. They are looking, instead, for ways to adjust to this reality, both internally in terms of service delivery and at the public policy level in the search for more equitable reimbursement.
What is the real problem?
"A year ago, 25% of our admissions died within the first 14 days. This July, 42% died within 14 days," reports Anne Thal, LCSW, DCSW, president and CEO of Hospice of Hillsborough in Tampa, FL. "You’ve got a problem there. The reality is that our first and last week are our most expensive."
Adds Jo Cunningham, MA, vice president of Lifespan Home Health and Hospice in Battle Creek, MI, "Our current average is 60, but our median is 30 or so. And we’re seeing increased numbers of patients for only three to seven days." Cunningham’s hospice estimates that its cost per day for patients enrolled seven days or less is four times higher than for patients who live longer.
"The overall trend is down," confirms Gretchen Brown, MSW, president and CEO for Hospice of the Bluegrass in Lexington, KY. With increased scrutiny from fiscal intermediaries, the Health Care Financing Administration, and the Office of Inspector General (OIG), "we’ve lost the people at the longer end, which makes us more aware of the short-stay issue. I also think cancer patients are sicker these days," Brown says.
However, other hospice managers wonder if patients are truly coming to hospice later, or is it instead penetration into new patient populations? "Length of stay could be really short because you’re doing a good job of responding to crisis referrals," observes Christi Whitney, RN, MS, president and executive director of Grand Valley Hospice in Grand Junction, CO.
"We’ve always had a fair number of short-time patients between 35% and 50% enrolled for less than two weeks on a regular basis, over the past 10 years," observes Rodney S. Taylor, executive director of Hernando Pasco Hospice in Hudson, FL. "Now everybody is feeling the pinch, and the reality is that we’re going to struggle with it financially. I don’t know that there’s a good answer, but I don’t see it with quite the same doom and gloom as some hospice executives," he says. "Down here we’ve always treated it as crisis management. You don’t get the ideal hospice scenario, but I’m not uncomfortable with that. I’ve always seen our role as dealing with as many dying patients as possible."
What can you do for patients in a week?
For Peter Moberg-Sarver, CEO of Hospice of Central New York in Syracuse, the issue is not how to bring length of stay back up to previous levels or promote earlier referrals, but "what services can we provide to patients in one week or less? I’m not sure it’s different than any other crisis intervention service. I wonder if anybody in hospice is really pushing the envelope and developing crisis response teams."
"The patients we now get for less than a week, before, we never would have gotten them at all. They would have died in the hospital," adds Connie Holden, RN, MSN, director of Boulder County (CO) Hospice. "Some in hospice might say, Let them die in the hospital, because they’re killing us financially.’ I don’t say that, because in the long run, their families might have a good hospice experience and remember it. These very short stay patients benefit from hospice, and in some ways, we do, too. Although, obviously not monetarily."
A number of reasons have been offered by hospice managers for the continuing problem of very short stay patients. These include old standbys such as a general lack of awareness and understanding about hospice, reactions to its close association with death, difficulty in determining a terminal prognosis, and the effects of the OIG’s Operation Restore Trust, focused medical review, and increased government scrutiny. "One of the biggest barriers for physicians is the need to prognose patients accurately," Whitney observes. "How many times do we have to hear it? It shouldn’t be downplayed how difficult that really is for physicians," both medically and emotionally.
Current financial incentives may now be pushing other health providers to hold onto patients longer. More patients are utilizing Medicare’s skilled nursing benefit for transitional care after discharge from the acute hospital, while home health agencies are expanding their roles and reach in end-of-life care. But those incentives may change dramatically when prospective payment for home health care is finally implemented.
"People make a lot of this issue, and certainly home health agencies and hospitals are hanging onto patients longer. But I think it’s more patient/family-driven, a reluctance to embrace hospice," Moberg-Sarver says.
"Part of the problem is the word hospice that’s just the stopper for many patients," adds Marilyn Hannus, director of Hospice of Cape Cod in Yarmouthport, MA. "As hard as we fought to get recognition for hospice, we’re now shooting ourselves in the foot with our name. We have to broaden our definition."
The influence of managed care and even the anticipation of potential changes under managed care also seem to be suppressing referral activities throughout the health care system. "In our service area, none of us are getting new referrals like we used to. Even in certified home health agencies, the number of visits is down," Hannus reports. "We think that has to do with physicians beginning to look at the impact of managed care on their own practices. They’re battening down the hatches." Managed care case managers may also be using a tighter approach, controlling and doling out the services their patients receive.
"There’s a psychological aspect to this with other providers holding onto patients just to feel some control over their destiny," in a turbulent health care system, suggests Jacob Blass, MA, president and CEO of Hospice of Metro Denver. "In Denver, which is a heavy managed care arena, physicians and other providers are so concerned about revenue streams that they lose sight of the expenses they may be incurring," by not referring patients appropriately, he adds. "What makes it more complicated is that the HMO and the physician don’t want to be accused of letting the patient go too soon for financial reasons," referring to hospice instead of approving potentially lifesaving treatment.
Chemotherapy nausea now easier to manage
Changes in treatment, particularly for cancer patients, also impact on the timing of hospice referrals. "With the new medications, physicians are better able to cope with the side effects of treatments such as chemotherapy," says John Ceynar, RN, CRNH, admissions coordinator for HealthSpan Hospice in Roseville, MN. "We think the benefit/burden ratio has changed for some of these treatments. Chemotherapy-induced nausea is now fairly easy to manage. Plus, people are looking for the silver bullet," which will cure their disease, he relates.
"In oncology there are numerous protocols and clinical trials that just were not available 10 years ago," says Wendy Hawke, MD, former medical director for Hospice Atlanta and now a palliative care specialist with Georgia Cancer Specialists, a 20-plus member oncology group practice based in Atlanta. "There is a new push from pharmacy companies to use their products and engage in more clinical trials. There’s a great deal of research on the benefits of multimodality approaches to cancer treatment. Patients who receive radiation therapy will have their hospice referral delayed at least six weeks," unless the hospice is willing to pay for the therapy, at several hundred dollars a day, she says.
Since Hawke joined the large oncology group, its referrals to hospice have tripled. So has the average length of hospice stay, from nine to more than 30 days. Having seen the issue from both sides, she now observes, "Hospices need to come up with creative solutions and analyze this population. If the economic ramifications for physicians from making referrals to hospice are negative, you need to find new ways that are not so negative." Hospices also need to find creative new partnering strategies with physicians and other providers, she says.
Since cancer treatment trends may limit the potential for increasing length of hospice stay, some executives are exploring growth in the non-cancer diagnoses, using the Arlington, VA-based National Hospice Organization (NHO) Medical Guidelines for Defining Prognosis in Selected Non-Cancer Diseases. Efforts by fiscal intermediaries’ medical directors to turn these into local medical review policies are continuing to generate controversy among providers. (See story, p. 5. Also, see HMA, November 1997, pp. 130-131.) But for those patients who fit the criteria, hospices can enjoy a higher level of confidence about the admissions.
Finding hospice’s role in the midst of crisis
"Very few cancer patients are going to last six months. The ones that tend to live longer are the same ones the fiscal intermediaries are now looking at more closely," observes Pamela Melbourne, RN, MN, Director of Clinical Services for Hospice Atlanta, a Division of Visiting Nurse Health System. "We’re beginning to implement the non-cancer guidelines with our referral sources. We feel they give us a format for documenting terminal status, without having to err on the side of being too conservative or to discharge [stabilized] patients too soon."
Adds Porter Storey, MD, medical director of the Hospice at the Texas Medical Center in Houston, "I’ve been trying to use NHO’s guidelines as tools to educate referral sources about who is terminally ill. That is beginning to bear fruit. I went over and talked to the Alzheimer’s Association recently. I can now say, Look, this is what an appropriate Alzheimer’s referral looks like,’" he explains. "It’s also important to be doing research. We now have an MPH student doing chart reviews for us."
Ultimately, however, short stay patients may be a reality hospices will have to accommodate themselves to. While there may be important financial implications to that conclusion, the clinical reality might not be as bad as some providers have believed.
"I don’t think we’ll ever go back to what we knew before," Holden says. "So we have to acclimate, the same as hospitals. They had to adjust to DRGs. Much as we don’t like it, we maybe need to develop short-term crisis teams and adjust our staffing accordingly."
"We need to figure out how to stay alive and how to help our staff cope because they still haven’t shifted out of the old paradigm or gotten used to the new [higher] acuity," she adds.
"We recently tracked whether patients and families in the program less than seven days were any less satisfied," Ceynar says. "In fact, once we took out the outliers, they were our most satisfied group. One of the theories we came up with is the white horse syndrome hospice came riding in on a white horse and made a big difference quickly." Longer term patients and families may not experience the same sense of crisis and may bring higher expectations, he explains.
"We’ve been doing our own study to look at where people are in terms of satisfaction," adds Jan Cetti, BSN, MS, CEO of San Diego Hospice. "There is conventional wisdom about short stay patients in hospice, but why do people need to stay in hospice longer? If it’s just about money and if people feel it’s a big problem, let’s change the payment system."
"If it’s comforting to the family, who are we to say it’s not the right approach?" concludes Susan Goldwater, executive director of Hospice of the Valley in Phoenix. "We have all our idealistic notions about beautiful hospice care and it is beautiful but it’s also speckled with these other issues," such as financial sustainability and barriers to access, she says. "The reality is hard to cope with. We’d like to design the ideal hospice program and have our families rally around it. But the reality is that hospice is now dealing with the same difficult patients the larger health care system has always had a hard time dealing with."
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