Is hospice retreating from commitment to admit terminal non-cancer patients?
Government scrutiny leads providers to be cautious
There's evidence that regulatory pressure has caused America's hospice industry to retreat from its long-standing commitment to create access for patients with terminal diseases other than cancer. Data from the Washington, DC-based Hospice Association of America (HAA) suggest that one unintended consequence of Operation Restore Trust (ORT), focused medical review, and other forms of increased government scrutiny is a distinct reduction in the proportion of non-cancer admissions to hospice.
This trend reverses a slow but steady growth in non-cancer admissions by U.S. hospices, which once served cancer patients almost exclusively. The current roll-out by Medicare fiscal intermediaries of local medical review policies (LMRPs) for non-cancer admissions may exacerbate the problem by making hospices and their referral sources even more cautious about signing up such patients. Industry leaders contacted for this report say they do not have data to corroborate the HAA's finding, but add that they would not be surprised if it were true. (For HAA data, see chart below. For further discussion of LMRPs, see Hospice Management Advisor, September 1998, p. 115.)
"I wouldn't be terribly surprised if it were true," says Stephen Connor, PhD, vice president of research and professional development for the National Hospice Organization (NHO) in Arlington, VA, but added he could not confirm the trend. The NHO's most recent comprehensive hospice census covers the year 1995, while a non-randomized "fax-back" survey of its members by the NHO last fall suggested a smaller drop-off in the non-cancer proportion. "There are a lot of data floating around, and we have to be careful about jumping to conclusions," Connor says. If the non-cancer fall-off were confirmed, however, it would be an important message to deliver to the Health Care Financing Administration (HCFA) in Baltimore, he notes.
Too much caution is risky
The HAA's May 1998 Hospice Facts & Statistics, based on data from the National Center for Health Statistics' National Home Health and Hospice Care Survey, indicate that just over 70% of patients discharged by hospices between October 1995 and September 1996 presented neoplasms (cancer) as their primary admitting diagnosis. Several other classes of diagnoses often associated with hospice care - heart, lung, and nervous system disease (especially Alzheimer's), and AIDS - accounted for 23.5% of admissions. The remainder had miscellaneous other illnesses or were otherwise missing from the totals.
Compared with 1994 data showing 59% with neoplasms and 29% with the other disease categories listed above, the later figures seem to suggest a retreat from non-cancer diagnoses simultaneous with the government's stepped-up scrutiny of hospices. Since the HAA's data predate this year's implementation of non-cancer LMRPs, the current picture may be even worse. These LMRPs have generated sustained controversy among hospices as a potential barrier to hospice access for dying patients who don't quite fit their criteria.
While some hospices may shy away from non-cancer patients out of a fear of coverage denials, or charges of fraud and abuse, excessive caution in this arena may come back to haunt the industry. If access to hospice care for non-cancer patients is restricted, it could further marginalize hospice's role in the emerging growth industry of end-of-life care while strengthening the case for those who want to develop end-of-life alternatives to hospice.
"It makes sense," adds J.R. Williams, MD, chief patient care officer for the Miami-based Vitas Healthcare Corp. hospice chain. "I have heard of hospices, particularly small ones, that are afraid of LMRPs, because the relative risk from a [claim] denial is so much greater [given their smaller budgets]," Williams says. And LMRPs are just part of the overall process of regulatory constraint on hospice.
"What happens now, with sequential billing, is that you can't send in another bill on a patient until all intermediary requests for additional information on the previous bill have been resolved. This is interrupting cash flow," Williams explains. "Predictions were made by some that hospices would restrict access because of LMRPs, by tightening their admission policies. I think it's a shame. It's no way to run an industry, and it further squeezes hospice, which I think is the ideal model for end-of-life care."
Model LMRPs for non-cancer admissions to hospice were proposed last fall by a committee of home health/hospice fiscal intermediary medical directors, building on the NHO's Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases. The guidelines had been developed by the NHO's Research Committee, at HCFA's request, in response to growing concerns about inappropriate non-cancer admissions and long-stay patients. However, the NHO's guidelines were designed to encourage hospices to admit appropriate non-cancer patients, and were never intended for the more prescriptive purposes of the LMRPs, the guidelines' authors have repeatedly stressed.
A new NHO ad-hoc task force has been gathering data to document problems with the LMRPs, and has met with NHO leadership and with Tom Hoyer, HCFA's director of the Office of Chronic Care and Insurance Policy. Participating hospices have retrospectively reviewed charts of their non-cancer patients enrolled on the benefit, with the result that a quarter or more would not have qualified under model LMRPs, even though they died within six months of hospice admission.
Fiscal intermediaries are taking different approaches and time lines for implementing the non-cancer LMRPs, and have made some changes in response to providers' input. However, NHO's LMRP committee is still pushing for suspension of the policies until they can be validated by research.
"My personal view is the policies should be suspended. There's no evidence to suggest that they have been properly verified," says Amber B. Jones, MEd, president and CEO of the New York State Hospice Association, in Albany, and co-chair of the NHO's LMRP task force. "I think they are creating an access problem, but how we will get the data to prove it is an interesting question." Medicare data only reflect patients who enroll on the benefit, not the effects of physicians' reluctance to refer people to hospice because of their reading of the regulatory climate, Jones says.
Brad Stuart, MD, medical director of VNA and Home Hospice of Northern California, Emeryville, and a principal author of the NHO's non-cancer guidelines, has been participating in periodic conference calls with fiscal intermediary medical directors, trying to make the policies more workable for hospices. "I'm still cautiously optimistic that what we have is fairly workable within the limits of what the law says, and that we are developing a system that will allow claims to be approved," he reports. "I'm not aware of any large-scale denials of patients, even if they don't fit the criteria. I am seeing evidence that the fiscal intermediary medical directors are anxious to defuse the perception that they want to do large-scale denials," Stuart says.
"At least in Blue Cross of California's region, they are trying new, whittled-down versions of the LMRPs," Stuart says. The first two of these, for heart and pulmonary diseases, were implemented Aug. 1. "More importantly, we came up with a list of parameters for functional assessment criteria that can be used to document 'evidence of rapid decline.' That is how hospices can get past the bottleneck for patients who don't fit the criteria. HCFA and the fiscal intermediaries say that if the hospice can document evidence of rapid decline, it can get the patient on the benefit and even recertify," he reports. (For information on how to document evidence of rapid decline, see related article on p. 119.)
Teaching nurses is key
"If we as an industry work to develop consistent documentation and train our staff to document evidence of rapid decline, we may even see some rebound in length of stay. Key to the whole process is to get the hospice medical director involved in teaching hospice nurses to make their documentation more medical."
Stuart declines to take a position for or against suspending the LMRPs until they can be validated. "If they were suspended, I'd be quite happy to work with that, because there would be more time to test their validity. But I also feel we have a system that probably will be workable, if providers stick with it," he observes. "I've tried to build a bridge between hospice patients, providers, and the people who pay them. I think working to build constructive, well-functioning relationships between providers and fiscal intermediaries will produce the best results."
There still will be denials and prognostic uncertainty, Stuart says. "That's the trouble with hospice. The hospice benefit has serious and critical limitations that you'd better believe will be enforced by HCFA. That's probably the way it should be, because that's what the law says. Let's change the law - I'm all for that. Let's develop new systems of care that go beyond hospice," he adds.
"Some people are concerned that we are denying care to patients who are very sick but have longer than six months to live. I believe that is true," says Stuart. "Hospice people have to accept that if they want to provide care to very sick patients having longer than six months to live, the Medicare hospice benefit may not be the appropriate vehicle."
In the meantime, there shouldn't be a single patient who is clearly declining and appears terminal denied enrollment in hospice because of provider fears of reimbursement denial, says Stuart. "We have so many patients dying quickly in hospice, a few dying slowly shouldn't be a big deal. We should be more aggressive about enrollments and recertification, but in order to do that, you must know how to document."
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