OIG once again advises collaboration with HCFA
Report points to potential anti-kickback violations
A second report on hospice in the nursing home, focusing on hospices’ contracts with nursing homes, has been released by the federal Office of Inspector General (OIG). (See Hospice Management Advisor, December 1997, pp. 138-139.) However, it contains little that’s new or surprising. The report reiterates the OIG’s earlier recommendation that the Health Care Financing Administration (HCFA) and industry representatives collaborate on solutions to identified vulnerabilities in the hospice benefit for nursing home residents.
The earlier report, "Hospice Patients and Nursing Homes," found a lower frequency of services for nursing home patients, overlap of services between the two providers, and questionable hospice enrollments, as well as questioning whether current dual reimbursement rates are set too high.
For the new report, OIG’s Office of Evaluations and Inspections’ regional office in Chicago reviewed financial records of 22 hospices with patients residing in nursing homes. While this does not represent a random sample, it produced the following findings:
• Almost all of these hospices paid nursing homes the same as or more than what Medicaid would have paid the facility if hospice were not involved. Instead of the 95% rate for the facility’s room-and-board services, as specified in Medicare regulations and paid to the hospice as a pass-through, most of the reviewed hospices paid 100% to 120% of the daily Medicaid rate to their contract nursing homes.
• The hospices paying more than 100% of the Medicaid daily rate to contracting nursing homes also had a higher percentage of patients in nursing homes, in some cases nearly 100% of their caseloads.
• Both the hospice and the nursing home potentially can benefit financially by enrolling more patients in hospice.
• Some hospice/nursing home contracts contain provisions that raise questions about inappropriate patient referrals and potential abuse of Medicare anti-kickback statutes.
The new report recommends that HCFA "work with the hospice and nursing home communities to help them avoid potentially fraudulent and abusive actions that might influence decisions on patient benefit choices and care," in violation of the anti-kickback statutes. It also charges HCFA to work with the states to develop regulations to clarify what is included in the hospice nursing home room-and-board rate.
The OIG plans to distribute this report to the two industries and to Medicare fiscal intermediaries. In an appendix to the report, HCFA indicates its agreement with the findings and recommendations. J. Donald Schumacher, PsyD, chairman of the National Hospice Organization (NHO) Nursing Home Task Force and President of the Hospice Association of Western New York in Cheektowaga, also concurs with the recommendation that HCFA collaborate with industry trade groups to clarify and enhance the hospice nursing home benefit.
Schumacher’s task force will be issuing a report to the NHO Board of Directors in mid-April, "including recommendations for the next phase, working with HCFA," he says. "This has bought us a little time to try to figure this issue out."
[Editor’s note: Copies of "Hospice and Nursing Home Contractual Relationships," issued by the Department of Health and Human Services, Office of Inspector General, November 1997, OEI-05-95-00251, can be obtained from OIG’s Chicago Regional Office at (312) 353-4124.]
A new advocacy organization named Americans for Better Care of the Dying (ABCD) was unveiled by its founder, Joanne Lynn, MD, at a December press conference in Washington, DC. A nonprofit organization dedicated to social, professional and policy reform, ABCD is now seeking nationwide grass-roots support. "We can learn to improve care significantly in the next few years, without raising costs. The time has come to demand a better deal for the dying," says Lynn, who is director of the Center to Improve Care of the Dying at George Washington University in Washington, DC.
"We hope to enroll thousands of members, and to work at all levels local, state, and national," to demand quality of care for the seriously ill, answer media inquiries, and draft informed policy, she adds. Tax-deductible, $50 memberships in ABCD will be used to support meaningful change in end-of-life care.
ABCD also will emphasize improving communication, supporting innovation, and "getting people in key policy positions to routinely begin asking the question: How does this decision affect people who are seriously ill?’ If we can get that question pervasively on many people’s screens, we’ll start doing things right," Lynn asserts.
The organization has launched a newsletter titled ABCD Exchange. Its guidebook, The Advocate’s Guide to Better End-of-Life Care, is intended to help the general public get involved in end-of-life policy debates and is available for purchase. Two books, The Handbook for Mortals and The Sourcebook on Dying for Health Care Managers, are being prepared by ABCD staff under contract with Oxford University Press and should be published in the next 15 months.
As of the press conference, about 100 health professionals had signed on board as members of ABCD, Lynn reports. Will this organization achieve its goal of becoming a true grass-roots voice for improving end-of-life care? "We’re very new; ask me later," she replies. "We’d welcome hospices as members, although we hope to have a voice somewhat different than hospice’s not different than the hospice philosophy," but different from hospice’s current focus on a six-month prognosis, she explains. "We’re looking to try to be helpful to hospice as it faces its own crossroads which way to go? The human resources, the track record, the learning in hospice are very precious and are the foundation from which the best [in end-of-life care] can be built."
• • •
At the press conference introducing ABCD, Lynn also presented a letter of commendation to Kenneth Kizer, MD, Undersecretary for Health for the Department of Veterans Affairs, in recognition of the VA’s efforts to improve end-of-life care and care planning. The VA’s current national strategy for achieving reliable, excellent palliative and end-of-life care building on the findings of the Institute of Medicine’s June 1997 report, Approaching Death: Improving Care at the End of Life, aims to:
• identify and disseminate best practices in care of the dying;
• design educational programs for VA health professionals and for patients and families;
• strengthen outcomes measurement methods;
• collect data on quality, access, cost, and utilization;
• identify priorities for future research.
VA’s 1997 national performance standard for end-of-life care (see box on p. 23) improved 15% in three months for those veterans with advanced, incurable conditions who received documented end-of-life care planning. The VA is planning an invitational national end-of-life summit for this spring, and the VA also is completing a congressionally mandated National Hospice Study, with an April 1, 1998, deadline. "We’re planning to use information from that survey to get some additional sense of direction," says Bonnie J. Ryan, the VA’s chief of community-based care and a former hospice director in Illinois.
Currently, every VA medical center must have a hospice consulting team in place. Many also have their own hospice program or unit, or else refer patients to community-based hospices. This has been a challenge, Ryan says, because Congress allocated no additional funding for hospice care when it mandated hospice in the VA system.
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MediCaring Update: An invitational meeting was held late last year in Washington to explore the concept of MediCaring, a policy proposal developed by Dr. Lynn and the Center to Improve Care of the Dying. (See story in Hospice Management Advisor, December 1997, pp. 140-141.) MediCaring would rechannel Medicare funds for patients who have incurable diseases that are likely to be terminal away from aggressive curative treatment and toward more supportive, community-based care. This approach is very loosely patterned on hospice but would cover a longer time span in the progression of life-threatening illnesses.
The meeting generated a great deal of enthusiasm, as well as an appreciation of the challenges involved in launching MediCaring demos, Lynn observes. But despite these challenges, she hopes to keep to the proposed time line of submitting a request for Medicare waivers to HCFA later this spring in order to launch 6 to 12 demonstration projects (some with multiple sites) by the fall.
"We’ve gotten overwhelming response, much more than we could include in the demos. For that reason, we’re putting together a meeting in February for all those parties working in this area who won’t be part of the demos but want to learn the same information," Lynn adds. Additional details on this gathering, which has the working title of "Innovator Meeting," were not available at press time.
[For more information on ABCD, contact Janet Heald Forlini, JD, director of Development and Policy, at 2175 K St. NW, #820, Washington, DC 20037. Telephone: (202) 530-9864; fax: (202) 467-2271; e-mail: [email protected]. The Web site is: www.abcd-caring.com. For information on the VA’s end-of-life initiative, contact Bonnie Ryan at (202) 273-6488. For more information on MediCaring, contact the Center to Improve Care of the Dying, (202) 467-2222.]
Editor’s note: In this issue, Hospice Management Advisor launches a new feature, News from Home Care. In a turbulent health care system progressing unsteadily toward integration, what happens in home care has relevance for the future of every hospice in America. The need to clarify relationships with home health agencies and the process of referral to hospice have challenged hospice managers since the industry’s earliest days. Planned national reimbursement policies such as home care prospective payment are likely to have a tremendous influence on hospice referral patterns. For many American hospices, which are departments of home health agencies or are dually certified with their own home health license, tremors in the home care business directly affect their bottom lines.
Although hospices may not want to believe it, home care has also fared worse in Operation Restore Trust and other government anti-fraud initiatives. News of home care’s troubles and advances thus can provide a balancing perspective on the issues hospices face. Drawing on resources such as American Health Consultants’ fleet of home care-oriented publications, as well as industry leaders who have a foot in each camp, this new feature will digest the leading issues facing the home care industry, with an eye to underscoring their relevance for hospice managers.
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