Proactive QI needed for nursing home residents
Government reprieve only temporary
One outstanding issue for hospices resulting from Operation Restore Trust (ORT) is the quality and value of hospice care provided to nursing home residents. Some hospices have begun to review their own standards and services in order to proactively address this issue, which is not likely to go away.
Although it now appears unlikely that the Clinton Administration will seek this year to eliminate the hospice benefit for residents of Medicaid nursing homes, administration concerns remain. "It’s very important for the hospice community to look at this benefit, how it’s structured and how it’s paid for and to come forward with proposals to address the concerns that have been raised" by the Office of Inspector General (OIG), among others, says John J. Mahoney, President of the National Hospice Organization (NHO) in Arlington, VA.
The NHO has appointed a Nursing Home Task Force, chaired by J. Donald Schumacher, PsyD, president and CEO of Hospice Association of Western New York in Cheektowaga, to look at these concerns and produce guidelines for providers. The task force is considering "what we can do as an industry to clarify the benefit and to make recommendations [to providers] on how we can improve the picture internally," Schumacher says. NHO also hopes to work with the Health Care Financing Administration (HCFA) on clarifying regulatory intent for providers.
"I think there have been some inconsistencies within the industry in terms of providing hospice care in the nursing home. That is what led OIG to raise its concerns, although those concerns probably have been drifting around HCFA all along," Schumacher says.
The dual reimbursement system paying the hospice for hospice services and for nursing home room and board services for which Medicaid is responsible, with the hospice passing the latter on to the nursing home is viewed by some in HCFA as confusing, fraught with potential for abuse and potentially even double-dipping from government reimbursement.
"I don’t believe there’s a lot of intent to abuse the benefit by hospices, but there’s a lack of good specific guidelines for how to do this right. If there are bad apples,’ the best way to deal with them is to clarify what we all ought to be doing in the nursing home," Schumacher says.
Among the concerns Schumacher’s group is examining are questions of who is contractually responsible for which duties in the nursing home setting, how contracts for services are defined, and disparities with what is provided to hospice patients living at home.
"The nursing home issue is a real lightning rod," adds Mary Michal, JD, a health care attorney specializing in hospice for the law firm Reinhart, Boerner, Van Deuren, Norris & Rieselbach in Milwaukee. "It underscores how hospice’s efforts to increase access can run amok. Where’s the line between making sure every terminally ill person has access to hospice care, regardless of setting, vs. aggressive marketing that improves the hospice’s bottom line but doesn’t add value to patient care? That’s what nursing home operators are asking me. I hear horror stories about aggressive marketing approaches and inappropriate admissions where no value was added," by the hospice, Michal says.
"Part of the issue, too, is that nursing home regulations are going through such flux, and so much is at stake for nursing home administrators, including increased civil monetary penalties for violations."
Although clearer guidelines for providers are still under development by the NHO and others, experts offer some interim suggestions that hospices can use for self-assessment:
1. There should be no difference in the frequency and level of hospice services provided to patients residing in nursing homes compared with those living in their own homes.
"I would recommend that you talk to other programs providing these services, and begin to do qualitative and quantitative analyses of what you provide and how you’re doing it," Schumacher says. "If you can’t reconcile what you’re doing in the nursing home with what you do for patients at home if you’re interpreting the benefit differently based on setting you are incorrect."
2. Hospices need to become more familiar with nursing home regulations and reimbursement.
"That is essential because right now the two sets of regulations aren’t meshing," Michal says.
Take, for example, Medicare’s skilled nursing facility benefit, which is available for a limited number of days following acute hospitalizations for certain conditions. If a hospice patient clearly needs to be in the nursing home upon discharge from the hospital and is not Medicaid-eligible, then failing to take advantage of eligibility for for Medicare skilled nursing coverage could mean a major out-of-packet expense for the family even though it would require disenrolling temporarily from the hospice benefit, Michal points out. "We at least have to make sure our patients and families understand their range of choices and the fiscal considerations."
3. Be careful about anti-kickback statutes in contracting with nursing homes for room and board at a rate higher than 95% of the prevailing nursing home reimbursement rate which is what the hospice is paid by the government for room and board.
"This has to be done carefully. You need to demonstrate what you’re paying for, in an arm’s-length transaction, because there are serious anti-kickback concerns involved," Michal says.
4. Michal also urges hospices to make sure their contracts with nursing homes are not just worked out by administrators, but involve clinical protocols and feedback from staff at all levels in both organizations.
"The successful contract takes a lot of time to implement, and it requires an intense amount of communication."
5. More data are needed on the level and types of services being provided to hospice patients in the nursing home and the outcomes from such care, compared with similar patients not on the hospice benefit.
For example, does provision of hospice services reduce the likelihood that patients will be transferred to an acute hospital for the final days of life?
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