GAO to examine hospice access under Medicare
End-of-life skills needed in other care settings
The Health Care Financing Administration (HCFA) is paying more attention not only to hospice, but also to systematically institutionalizing hospice care, according to Thomas Hoyer, director of HCFA’s Office of Chronic Care and Insurance Policy. "There has been a lot of national interest in end-of-life care," he recently told a group of hospice providers.
Currently, he said, the General Accounting Office (GAO) is working on a study that will address hospice access under Medicare.
Additionally, the Medicare Payment Advisory Commission recently devoted a chapter to end-of-life care in one of its reports to Congress, and plans some additional work on end-of-life services.
Hoyer said these developments reflect "a growing consciousness" that end-of-life care must be addressed. "For years, I have been saying one way or another it has been HCFA’s desire to continue to build the conditions of participation [CoPs] in ways that guarantee quality care," he said. But he adds that this does not necessarily mean that all senior patients require hospice care.
"In an ideal world, in which perfect success is achieved, you would have to ask yourself why any Medicare beneficiary would need to elect hospice," Hoyer said. "What would be the additive value?"
Rather, he said, hospices must assess where they fit in the current health care delivery system. "Clearly, you fit as hospices," he asserted. "In addition to that, it seems to me there is a future in helping hospitals and skilled nursing facilities, home care agencies, and health maintenance organizations by using your skills and making them more responsive to the end-of-life needs of patients."
Hoyer says the response of Medicare and Medicaid and the overall health care system to end-of-life issues over a long period of time is yet to be seen, however. "I think it is unrealistic to think that the answer to this issue is for hospices to, in effect, have all of the end-of-life business that there is.
"The answer is for all of our providers to do what they need to do, which is to learn a whole lot more than they know about end-of-life care and provide it properly," argues Hoyer. He adds that hospice can be a critical part of this movement. "But you have to remember that you can’t simply gather all persons with terminal illnesses in the hospice," he warns. "You have to also go out of your hospices and into these other providers and find a way to bring your knowledge and skills to them."
Power of persuasion
According to Hoyer, that highlights the need for community education. "The terminal prognosis is now six months, and I know the median length of stay as opposed to the average length of stay in hospices is not long," he says. "This means there is a fairly long period of hospice election still available to be made by people who still need to be persuaded that it is appropriate."
He says that might encompass referrals by physicians who still need to be persuaded that it is appropriate or hospital discharge planners who still need to be convinced hospice care is appropriate. "Those are burdens that are on the hospice community as the one community that ought to know what is at stake," he notes.
According to Hoyer, the GAO is now collecting everything they can get their hands on regarding hospice in order to study the issue, but the agency is primarily focusing on access. "They have been asked to look at access because of the fact that people have suggested the relatively short median length of stay in hospices may suggest that the rates may be too low or rules that may be unfair to hospice election," says Hoyer. "This is where the GAO is at the moment — attempting to find out whether the problems are systemic or social or a bit of both," he adds. "I have no reason to think that they won’t cast a broad net, and I am hopeful that their report will shed some light on this issue."
In terms of cost, Hoyer says, most hospice providers realize that the end of the first cost reporting period recently passed. "By the end of this calendar year, we ought to have a cost report for just about every hospice in the country," he says. "The first year of any cost reporting system tends to be spotty compliance, but we will have a cost report from everybody."
Hoyer says HCFA has asked its systems administrators to perform some initial programming so the agency will have an electronic file and be able to do some analysis. "We are committed to doing analysis as quickly as possible to see what hospice costs mean to us in terms of our rates and expenditures," he says.
Jeannie Miller, technical advisor in HCFA’s Office of Clinical Standards and Quality, reports that her office is currently working on a draft of the revised CoPs now. "We are in the process of working with the current regulations, the revision they started prior to the Balanced Budget Act, and comments we have received from associations and providers," she explains. "The plan is to have the regulations out as a notice of proposed rule making in the fall."
Palliative care defined
Regarding the definition of palliative care, Miller says the proposed rule currently says that palliative care means treatment for the relief of pain and other uncomfortable symptoms by appropriate coordination of all aspects of care needed to maximize personal comfort and achieve relief from distress. "That is where we are at right now," she said.
Asked whether HCFA would include specific regulations to address beneficiaries residing in nursing facilities, Miller says HCFA is very concerned about this population. But she added that the Department of Health and Human Services’ Office of Inspector General’s (OIG) fraud initiative in this area is an OIG concern and responsibility, rather than HCFA’s. "Our focus in the CoPs is going to be on the quality of care and outcomes measures," she says. "We are currently drafting CoP language that will cover hospices providing care to residents in skilled nursing facilities."
Mavis Connelly, technical director in HCFA’s Continuing Care Branch Center for Medicaid and State Operations, reports that her office recently accumulated data on hospice providers in connection with survey and certification activities. Currently, she says, there are 2,275 Medicare-approved hospices, including 562 that are hospital-based, 22 that are skilled nursing facility-based, 758 that are home health agency-based, and 933 that are freestanding.
In FY ’99, Connelly says, there were 107 new hospices approved. "That is just one more than in FY ’98, which was 106," she adds. Connelly also reports 114 terminations, of which only seven were involuntary. In 1999, she says, HCFA surveyed 16% of the hospices, which is 2% more than in 1998. "I know we have a long way to go, but this is driven by the budget that we have to work with," she adds.
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