Controversy surrounds debate on the rapid decline’ clause
Clinical decline’ could be new standard
The debate over local medical review policies (LMRPs) for non-cancer guidelines last year focused on whether the Washington, DC-based National Hospice Organization-driven policies were too restrictive. Today the debate focuses on a clause inserted in each of the LMRPs designed to reduce their insensitivity to terminal cases that don’t meet the disease-specific criteria.
Often referred to as the "rapid decline" clause, it states: Some patients may not meet the criteria, yet still be appropriate for hospice care because of other comorbidities or rapid decline. Coverage for these patients will be considered on an individual basis with adequate documentation.
But the same clause that was intended to relieve the restrictive nature of the LMRPs may be too restrictive in its own right, the author of the NHO guidelines says. The term "rapid decline" is at issue because there isn’t a true definition of what "rapid" means, says Brad Stuart, MD, hospice physician with Visiting Nurse Association (VNA) and hospice medical director of Home Hospice of Northern California in Emeryville.
Fiscal intermediary Wellmark in Des Moines, IA, recently made an attempt to clarify the vague language by drafting guidelines for determining terminal status due to rapid decline.
In December, John Olds, MD, FACP, regional home health intermediary contractor medical director for Wellmark, sent a draft policy of rapid decline criteria to NHO for review.
Wellmark’s proposed criteria for hospices to indicate rapid decline as a reason for admission or recertification, in hierarchical order from most to least, are:
• Change in Karnofsky Performance Index or Palliative Performance Scale/Adapted Karnofsky. Documentation should show at least one stage decline in three months with baseline no more than 50.
• Progressive weight loss. Loss of weight should not be attributed to a reversible cause, such as depression. "Progressive" is defined as five pounds in 30 days or 10 pounds in six months. Other measures of weight loss suggested include skin fold measurement, bitemporal wasting, and girth changes. If available, decreasing serum albumen or cholesterol levels could be used as surrogate indicators of weight loss.
• Dependence in performing activities of daily living (ADL). Patient must show a need for assistance in at least three of the following ADLs: feeding, ambulation, continence, transfer, bathing, and dressing.
• Progressive dysphagia. Patient should have documented difficulty swallowing leading to inadequate caloric intake. Documentation must include a 72-hour calorie count. Criteria can be used to claim rapid decline if dysphagia leads to recurrent aspiration.
• Low systolic blood pressure. If patient has a systolic blood pressure less than 90 when prior readings showed systolic pressure greater than 90, this criteria could be used to claim rapid decline.
• Emergency room visits. Patient is admitted increasingly to emergency rooms for conditions other than those considered minor or self-limited.
• Functional Assessment Staging for Dementia. Hospices would have to prove at least one stage of decline in three months with a baseline no less than stage five.
• Pressure ulcers. Persistence or progression of stage three or four pressure ulcers in spite of optimal care, such as nutrition and debridement.
To support a claim of rapid decline, hospices would not have to meet any specific number of criteria. However, two or three of the top-listed criteria or four or five of the lower criteria would be expected, notes Olds.
Case in point
In a written response to Olds’ draft of rapid decline guidelines, Stuart described the following real-life scenario from a team meeting at VNA and Hospice of Northern California:
An 88-year-old woman’s physical condition has been declining as a result of Alzheimer’s disease. She suffers from dementia, but not enough to qualify under the newly adopted Alzheimer’s LMRP criteria.
Her fluid and food intake has dwindled to a point where it barely sustains life. She has withered to 69 pounds, but in the last three months her weight has changed very little. The woman is cared for at home by her husband who is barely able to cope even with the assistance of a home health aide who visits seven times a week.
The woman does not meet the Alzheimer’s LMRP requirement, and the hospice would be hard-pressed to prove rapid decline. Under the rapid decline guidelines, she would have to be discharged from care, leaving the husband to provide care he is incapable of providing.
"We elected to keep her on service because we expect her to die within a month or two," Stuart wrote. "We are able to document clinical decline in good faith, but under the draft criteria the patient does not come close to manifesting evidence of rapid decline. We would be compelled to discharge this patient or risk denial of our claim, a claim that on clinical and prognostic grounds is entirely justifiable. The scenario would characterize the majority of end-stage debilitated patients for whom we provide hospice services." (See related story on documentation on p. 43.)
Clinical decline’ recommended
In addition, Stuart notes the rapid decline guidelines would lead to denial of claims in cases where patients are obviously dying, but fail to exhibit enough decline during a benefit period.
"Often functionality, weight, and other draft policy parameters are preserved until shortly before death, whereupon they decline precipitously," Stuart says. "The clinical course of end-stage heart and pulmonary disease are both characterized by long periods of stability, punctuated by unpredictable downturns. It is very unusual for these patients to progress smoothly in a downward trajectory consistent with the demands of the draft policy."
By simply replacing rapid decline with clinical decline, Stuart observes, the restrictive language of the proposed guidelines would be alleviated, but still require hospices to document decline. In a February conference call between fiscal intermediaries’ medical directors, NHO representatives and Stuart, fiscal intermediaries were receptive to Stuart’s suggestions, he says.
If fiscal intermediaries incorporate the suggested modifications, the criteria set forth by Olds would remain essentially the same. References to rapid decline would be eliminated and replaced with clinical decline.
Using the 88-year-old woman, Stuart cited as an example of how the guidelines were too restrictive, the clinical decline requirements would allow the hospice to keep the patient, he notes. Instead of having to show the 69-pound woman had lost five pounds in the previous 30 days, the hospice would have to document subtle changes in weight or other measures of functional status in addition to an irreversible terminal prognosis.
According to Stuart, the changes he suggests in the proposed guidelines have the following advantages over the rapid decline criteria:
• emphasizes standards of documentation and enables hospices to agree on parameters of decline;
• gives reviewers specific domains of decline for hospice documentation;
• allows hospices to document more subtle evidence of decline, especially during the late stages of a terminal illness;
• forms a base for research on the domains of decline to better understand their relationship to terminal prognoses.
Whether fiscal intermediaries will incorporate the suggested changes in their own LMRPs, isn’t known, says Chris Cody, director of NHO’s National Council of Hospice Professionals. "Whatever goes to the intermediaries is up to the medical directors."
However, the process requires medical directors to submit their proposed policies to their respective fiscal intermediaries for advisory committee review.
Stuart says he remains optimistic that medical directors will adopt changes preventing decline criteria from being too restrictive, thereby preserving hospices’ intention of treating the terminally ill until the very end of life. "Under the changes, hospices won’t have to prove rapid decline," Stuart says. "That’s excellent. Hospices won’t have to refuse patients who are not declining fast enough."
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