Blue Cross proposes new decline’ policy
FI follows Wellmark in easing restrictive clause
Blue Cross Blue Shield of California has proposed changes to its local medical review policies (LMRPs) for noncancer diagnoses, which could help providers make more timely referrals to hospice and be less restrictive for hospice recertification.
The proposed changes, which were issued for comment last November, resemble those adopted by another fiscal intermediary (FI), Des Moines, IA-based Wellmark, last June. And like Wellmark, Blue Cross’ proposed decline policy would move away from having to prove rapid decline in patients who are obviously terminally ill, but do not fit the requirements specified under LMRPs. Rather than having to prove rapid decline, which hospice experts argued would lead to the discharge of patients who were not declining fast enough, to proving a "decline in health status."
As with the Wellmark policy, the Oxnard, CA-based Blue Cross proposal is seen as positive step for hospices. It also signals a growing spirit of cooperation and trust among fiscal intermediaries and the industry, says Brad Stuart, MD, hospice physician with Visiting Nurse Association and Home Hospice of Northern California. Stuart was also the author of National Hospice Organization’s (NHO) guidelines for noncancer diagnoses, which became the basis of LMRPs.
"The FI medical directors were very receptive to our arguments," Stuart says. "They dropped their rapid decline idea and instead adopted the concept of documenting clinical decline.’ The parameters we agreed on a year ago were issued almost unchanged, first by Wellmark for their area, and apparently Blue Cross is following suit for the west. This development is probably not harmful to hospice, and in fact may be beneficial because we now know better how to judge whether patients are appropriate to enroll and keep, even though they may not be declining rapidly."
Opponents of the rapid decline clause in LMRPs argued the following points:
• Rapid decline requirements have a negative impact on hospice access because they require all hospice enrollees to be declining at specified rates. It would require hospices to refuse admission to all patients who are lingering near death, and also to discharge all those who were at the brink of death but not getting sicker.
• Documenting clinical decline within specified parameters is fair. It cues hospice staff as to which domains to measure when deciding on recertification.
• There would be future benefit to specifying domains for clinical decline. Gathered over time, the data could be used to do research on the clinical factors that actually might predict prognosis in dying patients.
The proposed change would require providers to show a decline in health status using sets of clinical variables. The emphasis would be on determining decline by establishing a baseline assessment and comparing it to follow-up assessments of the patient’s status Measurements used in both assessments could include change in Functional Assessment Staging, change in Karnofsky or Palliative Performance Score (PPS), weight loss, and dysphagia. Baseline would be established upon hospice admission or by using existing information that is available.
"Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this intermediary has established criteria for determining prognosis for several noncancer diagnoses, and published these criteria as intermediary policies," Blue Cross officials wrote to their Medicare providers. "However, not all terminal patients with noncancer diagnoses have diagnoses addressed by existing policies, and some patients with diagnoses addressed by current policies do not meet the coverage criteria established by the policies, yet due to comorbidities or other factors are expected to have a life expectancy of six months or less."
Clinical variables
Blue Cross says the clinical variable changes apply to patients whose decline is not considered to be reversible due to an intercurrent illness or condition. The variables are listed in the order of their power to predict poor survival, the most predictive first and the least predictive last. No specific number of criteria must be met, but fewer of those listed first (more predictive) and more of those listed last (less predictive) would be expected to predict longevity of six months or less.
The clinical variables are listed below in hierarchical order:
• Progression of disease as documented by symptoms, signs and test results.
• Decline in Karnofsky Performance Status or PPS/Adapted Karnofsky.
• Weight loss, decreasing anthropomorphic measurements — such as mid-arm circumference and abdominal girth — and decreasing serum albumin and cholesterol. The weight loss, however, cannot be caused by reversible conditions, such as depression or diuretics use.
• Dependence on assistance for two or more activities of daily living (ADLs), which include feeding, ambulation, continence, transfer, bathing, dressing.
• Progressive dysphagia, which includes documentation that would show difficulty swallowing, is 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. Hospices could show rapid decline if the patient is increasingly visiting 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 5.
• Pressure ulcers. Persistence or progression of stages 3 or 4 pressure ulcers in spite of optimal achievable care, such as nutrition and debridement.
"If the patient stabilizes so that death within six months since the last evaluation is not expected, that patient should be considered for discharge from the Medicare hospice benefit," according to the proposed policy. "Coverage for hospice patients who do not exhibit decline in the categories of clinical variables contained in this policy may be denied."
Blue cross expects to use the policy in two ways:
1. The fiscal intermediary would use it as criteria to review hospice claims for patients who qualify in part or entirely on the basis of decline in their health status for Medicare’s hospice benefit.
2. The hospice provider would use it as a guideline to determine eligibility of beneficiaries for hospice benefits based on decline of health status if there is no Medicare policy for a specific diagnosis or if the patient does not meet the criteria of existing policies.
The proposed change is the latest in the long road dating back to the implementation of LMRPs more than a year ago. Stuart explains that the original rapid decline language was put into the LMRPs because they feared FIs would interpret the guidelines to restrictively. By allowing a clause that allowed hospices to admit or recertify patients who showed decline in health, patients who did not meet the specific LMRP requirement could still invoke their hospice benefit.
"The Rapid Decline LMRP was sent to NHO and several of us who had participated in the original formulation of LMRP out of the NHO Guidelines," Stuart recalls. "In fact, we had pushed hard to get the rapid decline’ wording placed into LMRP in the first place so that the policies would not be too restrictive.
"Incidentally, we have been struck by how reasonable HCFA [Health Care Financing Administration] and the FI medical directors can be when a relationship of trust is built over time, and when arguments are advanced that are based on solid clinical experience."
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