Non-cancer guidelines resurface in review
Hospices wonder if policies are too rigid
An effort to formalize the Arlington, VA-based National Hospice Organization’s (NHO) Medical Guidelines for Defining Prognosis in Selected Non-Cancer Diseases as model local medical review policies for Medicare fiscal intermediaries has sparked complaints from some providers that the guidelines will take on a rigidity never intended by their authors.
The guidelines were developed in part as a response to concerns by regulators about hospice admission practices. Reviews of several hospices’ admissions last year by Operation Restore Trust (ORT) auditors concluded that the hospices owed millions of dollars in improper reimbursement for enrolling patients lacking proper medical documentation of a terminal status of six months or less to live, as required by Medicare. The hospices disputed this claim, and no attempts have yet been made to recoup the money. But ORT had a chilling effect nationwide on hospices’ admissions of patients with non-cancer diagnoses or ambiguous prognoses.
But how helpful are they?
NHO’s guidelines pulled together the best available medical evidence and expert opinion to use as a basis for determining a terminal prognosis for non-cancer diagnoses, including amyotrophic lateral sclerosis, dementia, HIV, end-stage heart, liver, pulmonary and renal disease, stroke, and coma. But Medicare reviewers need something more concrete in making decisions about whether to permit coverage for hospice admissions, says Richard Baer, MD, associate medical director for Medicare Health Care Service Corporation in Chicago, the regional home health/hospice intermediary for Illinois, Ohio, and Indiana.
Baer spearheaded the effort to turn NHO’s guidelines into Medicare review policies, working with NHO, the Health Care Financing Administration, and other fiscal intermediaries’ medical directors. The Illinois intermediary was the first to send the draft policies to providers in its region for comment, although other intermediaries are not far behind. Baer says he was surprised at comments from a number of hospices that the policies will be too cut-and-dried, closing access to some patients whose conditions, while clearly terminal, fail to fit the specified clinical criteria.
"The guidelines could have been a starting point for medical review not the end point," observes Diane M. Jones, MSW, ACSW, executive director of the Hospice Association of America. As published, they could have the potential effect of limiting access to hospice for patients who otherwise could qualify for the benefit, she says.
Are the policies too rigid?
"While we welcome some kind of structure and the opportunity to work from the same page, the kind of detail and the rigidity in the policies make me concerned. The hospice industry bought into these guidelines as guidelines. Converting them to policy has taken providers by surprise," Jones says.
"It’s written right into the policy that there will be patients who don’t fit the criteria but still could be considered appropriate because of other co-morbidities or rapid decline, as long as these are documented," Baer says. Coverage for such patients could be approved on a case-by-case basis. "But apparently that’s not enough reassurance for some hospices. If these policies had been out before ORT, hospices would have been in much better shape," he adds.
"We also have the ability to adjust and change them as new evidence comes out." Baer says he expects 85% to 90% of patients admitted under the guidelines to die within six months since it would be impossible to achieve 100% accuracy on prognoses. The guidelines could also help to overcome the current problem of very-short-stay patients, by providing hospices and referring physicians with the confidence to enroll any patients who meet the criteria. "With the policies, a lot more patients will be assured of coverage, even if they end up living longer than 210 days because they met the established criteria at the time of admission."
Baer adds that he is trying to educate providers about the policies and the opportunities to make them more responsive. Final policies, with whatever language Baer adds to allay providers’ fears, likely will be published Nov. 1, with a Dec. 1 implementation date for hospices in Illinois, Indiana and Ohio. Other intermediaries will probably follow a similar path of issuing draft policies for comment prior to implementation, although Baer says he hopes any substantial changes in the policies would be done through national consensus.
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