According to the Hospice Foundation of America, a hospice is "designed to provide comfort and support...when a life-limiting illness no longer responds to cure-oriented treatments." It means "accepting that death is approaching." The Foundation describes hospice as " 'something more' that can be done...when the illness cannot be cured" and death is likely within six months.
However, many "incurable" and "life limiting" conditions, from Down Syndrome, to spina bifida, to heart and lung diseases and dementia, are not terminal. They often respond to therapies, and sufferers can live on for years.
Medicare-Paid Hospice Admissions Must Meet Defined Criteria
Medicare and Medicaid, which pay for 93% of U.S. hospice services, impose three strict reimbursement requirements on end-of-life care agencies to discourage them from enrolling inappropriate patients:
- An attending physician and the hospice doctor must both certify that the beneficiary's illness is terminal and that individual has no more than 6 months to live if the illness runs its normal course; and provide a specific prognosis accompanied by clinical information or documentation supporting their position.
- The beneficiary or his/her representative must agree to and sign an election statement choosing the Medicare hospice, and agree to waive curative care.
- There must be a specific hospice plan of care which is reviewed periodically. It must include an assessment of the patient’s needs, address the management of discomfort and symptom relief, and state in detail the scope and frequency of services needed. The plan must be established by the attending physician, the medical director or physician designee, and an interdisciplinary group.
How Hospices Violate Medicare Guidelines for Nursing Facility Patients
In September, 2009, the U.S. Department of Human Services, Office of Inspector General ("OIG") released a report* of the continuing problem of widespread fraud committed by hospice agencies when nursing home residents are enrolled into hospice programs. OIG's report determined the extent to which hospice claims for beneficiaries in nursing facilities in 2006 met Medicare coverage requirements:
- Eighty-two percent of hospice claims did not meet at least one Medicare coverage requirement. Non-profit hospices were a bit more likely to be negligent in this regard than for-profit agencies.
- Thirty-three percent of claims did not meet election statement requirements. Most commonly, the statements did not clearly explain that hospice care was palliative rather than curative, or that the beneficiaries waived Medicare coverage of certain services related to their terminal illnesses.
- Sixty-three percent of claims did not meet plan of care requirements, such as a detailed description of the scope and frequency of services.
- For 31 percent of claims, hospices provided fewer services than outlined in beneficiaries’ plans of care. In some cases, there was no documentation in the medical records of any visits for a particular service.
- Four percent of claims did not meet the certification requirement of a terminal illness.
When is Hospice Appropriate?
Hospice was founded in 1974 on the premise that most dying patients suffered from cancer, a disease noted for its rapid decline. Now, Medicare is concerned about a rising number of hospice patients with non-cancer diagnoses who survive longer than six months, even for years, and the associated costs of treating them.
Sixty-two percent of hospice admissions now are for patients with non-cancer diagnoses and chronic diseases. Medicare pays hospices from $140 to $816 per enrolled patient per day, whether or not services are actually rendered or the patient is ministered to. This reimbursement scheme, which is vastly different from "regular" Medicare's payment-for-services provided model, has encouraged the growth of hospice from a grass roots cottage industry to a mainstream enterprise. Over half of the nearly 5,000 American hospices are for-profit.
Medicare is trying to reign in spiraling costs. Under a new proposed rule due to be implemented in 2010, physicians will have to write a "short narrative" describing the clinical evidence supporting their opinion of a limited life expectancy of six months or less. Presumably, an agency unable to provide solid evidence that a patient has six months or less to live will not be reimbursed.
* "Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance With Medicare Coverage Requirements"
George Daleiden - I was a science major in college and later a career member of the Institute of Food Technologists. I worked in the processed food and ...
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