HCFA suggests hospices have become careless’
Lessons to be learned from increased scrutiny
"Hospices have become, at minimum, somewhat careless," in how they meet Medicare requirements, observes Tom Hoyer, director of the Office of Chronic Care and Insurance Policy in the Health Care Financing Administration (HCFA) in Washington, DC, and long viewed as one of hospice’s strongest advocates within the federal government. The proof is that when regulators "start looking at hospice, they start finding things."
Operation Restore Trust (ORT) represents a wake-up call for the movement, in an era of greater regulatory scrutiny. (See cover story, p. 25.) "But I don’t know that this signifies a change in how hospice is viewed as a health care provider. This is just the first time it happened" to hospices, Hoyer says. In ORT, the Office of the Inspector General "hired peer review organization physicians real doctors who do real medicine to look at hospice medical records: Does it look like a medical record supporting a prognosis of six months or less? The vast majority of the patients have since died, so clearly it’s a problem of documentation of the kind that real doctors who practice in real hospitals would look for," he says.
Accurate documentation needed
Hospices respond that they are not used to this kind of intense medical scrutiny or the need to provide clinical evidence such as lab tests and biopsies in their charting. But Hoyer says they were always responsible to make and document a defensible determination that the patients they admitted were terminally ill with six months or less to live.
When the fourth hospice benefit period was enacted by Congress in 1990, it was assumed that this period would cover those rare cases in which mistakes in prognosis were made. Instead, the number of patients living beyond 210 days went up year by year. "This leads us to believe hospices started admitting patients of whose prognosis they were a lot less sure. Somehow, hospice people seem to have decided that the risk would go out of the business. . . . Now they say, Gee, there might be accountability. Gee, I might have to assume risk.’" For hospices to say they have become reluctant to admit non-cancer patients is self-serving and counter to the movement’s roots, he adds.
The Arlington, VA-based National Hospice Organization (NHO)’s recently updated Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases provides a good starting place for hospices wishing to meet the new documentation test, "and their fiscal intermediaries will also be glad to tell them," Hoyer says. "What needs to come out of all of this is better analysis of prognosis and risk both on our side and hospice’s," he adds. "Operation Restore Trust is a rite of passage. We learn something; life goes on. The hospice community can say, OK, now this lesson has been completed.’"
Other suggestions for providers, beyond doing a more thorough and careful job of documenting the patient’s condition on admission and at regular intervals, include trying to paint a verbal picture of the patient’s terminal prognosis and the basis for determining it. "You can’t generalize. Look at each patient and what diagnostic information is available for that disease. Clearly there are markers," says Ann Morgan Vickery, an attorney with the Washington, DC, law firm Hogan & Hartson and NHO’s general counsel. "I haven’t seen any evidence that hospices need to run MRIs on patients but, for example, with heart disease, can the patient walk across the room without difficulty in breathing?"
Formal utilization review may help
Hospice of Central New York in Syracuse has started a formal utilization review process at the beginning of each certification period, in which certain critical questions about prognosis always get asked. "After 210 days we institute 30-day review. At least we’re asking the basic question: Is this patient terminally ill? And then [we’re asking] more specific questions about the progression of disease," explains Peter Moberg-Sarver, the hospice’s president and CEO.
"We advise programs to do a good job and document appropriately," says Amber Jones, MEd, president and chief executive officer of the New York State Hospice Association in Albany. "But if people evaluate you and find you wanting, go back and look at the chart. If you think you’re right, appeal every time. I think hospice people need to get tougher not with patient care but on the management side."
"People have to understand that the sky is not falling," concludes NHO President John J. Mahoney. "Certainly the environment will become less open for hospice patients who aren’t literally on the brink of death. There are steps we can take and are taking to offset that impression. But we have to deal with it in the context of making sure people know that we take very seriously our responsibility not to [admit] patients inappropriately," Mahoney says.
"We are and will be under increased scrutiny. But we need to be certain we don’t let this issue begin to define us, so that we’re unwilling to take the risk of admitting the patient who needs our help. There will always be a certain amount of [flexibility] in hospice admissions." Mahoney also cautions hospices that other issues in OIG’s work plan have not yet surfaced in ORT reports, including concerns about hospices’ relationships with nursing homes and perceptions created from hospice marketing. "Given the business that we’re in, we not only have to be within the law, but we also have to be concerned about the perception. We have to be better than the law."
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