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This week the New York Times talks about the rising costs of providing hospice care in America with a particularly juicy hook about a nearly $25 million whistle-blower settlement against an Alabama hospice.  From there it talks about the focus of some hospices to seek patients who are likely to have longer lengths of stay, like dementia and stroke.  One research analyst even goes as far to say "It's a lucrative business, at least under the current reimbursement system."  They also feature an inspector general report that documentation for hospice patients in nursing homes was lacking. 

Not a good start from a newspaper that has actually been quite kind to hospice in the past.  The rest of the article goes on to discuss the various fixes including every hospice medical director's new task: the face to face certification visit.  (We have not yet dedicated a blog post to face-to-face home visits for certification, but one is in the works so we can has that out at a later date.)

But the article leaves out a lot and I feel it is pretty one-sided.  Apparently Don Schumacher, head of the NHPCO, has found some flaws in the article too as he is communicating with the NYT editorial board.  There is relatively little about potential changes to the payment structure to focus greater reimbursement during the first 7 and last 7 days of service when need is thought to be the greatest.  The article does not talk about or reference the article by another NYT reporter from 2007 with the title "In Hospice Care, Longer Lives Mean Money Lost" about the aggregate cap. Nor did it quote the Duke Study that found hospice care saved Medicare an average of $2,300 per beneficiary (OPEN ACCESS PDF), calling hospice “a rare situation whereby something that improves quality of life also appears to reduce costs.”  Yeah, they missed some stuff.

Which is not to say we need to look closely at fraud issues.  Good oversight is important for a multi-billion part of the health care system, but we have to realize that every problem started out as the solution to another problem.  The system is perfectly designed for the outcomes it gets.  So let your legislators know about what hospice means to you.  Talk to your organizations and actually answer the advocacy emails that moment instead of promising to get back to them later.

As the NYT usually does there is no ability to comment on the article but there is a linked blog post at "The New Old Age" which allows for comments.  As of this writing there are 64 comments.  Here are a few I thought stood out:

It is amusing and annoying to be complaining about the costs of hospice care, when in fact hospice patients are forgoing the ER visits, hospitalizations, specialists' visits, procedures, and many medications that Medicare would instead be covering if not for the patient making a decision to pursue comfort care only. So, what was the cost SAVINGS to Medicare by having these people on hospice, even though they stayed on longer than usual? Alot.- ras

I don't even believe desperate old people are gaming the system via hospice. But if they are, it's because this country has utterly failed them, taken payroll deductions for a lifetime in exchange for medical care in old age, and then only given the kind of medical care 70-year-olds need, not 90-year-olds. Shame on us. - jane gross

Hospice is a critical service that is offered to all. It is necessary, compassionate, and well run. So, if we discontinue it or cut services, we are a nation without merit and compassion. We will not only be third world, we should not be in this world. - Julie

The article disingenuously ignores this broader care issue while it exploits an example of an Alzheimer's patient. Please, NY Times, get perspective on the bigger picture. Help the US face its fear of dementia that keeps us in denial and prevents us from preparing to fight a huge healthcare tidal wave. Take more leadership and make a difference. - Suzanne

So it's too expensive to have an MD check on hospice patients once every six months? The health care industry has become even more shamelessly and barbaricly greedy than I thought. - Cowboy Marine

TAYLOR JR, D., OSTERMANN, J., VANHOUTVEN, C., TULSKY, J., & STEINHAUSER, K. (2007). What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science and Medicine, 65 (7), 1466-1478 DOI: 10.1016/j.socscimed.2007.05.028

Photo credit: Flickr user:  castle79

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The National Hospice and Palliative Care Organization and it's sister organization the Hospice Action Network are hosting Hill Day in Washington DC on April 6th where they lead hospice advocates from all over the country in meeting with government representatives to talk about the role for hospice in the continuum of our nation's health care delivery system.  They bring the stories and the data to appeal to both sides of the political brain and are meeting with both major parties.

The events started today with strategy sessions to make sure the advocates were prepared with the facts and how to make the most effective use of their time.   I have never attended Hill Day but would invite anyone who is attending this year or the past to write a guest post for Pallimed to recount your experience.  Activities like this are so important as anyone who has heard Diane Meier speak recently about her experience in Washington DC.  Her discussion about optics and the view from the Hill centers around the revelation that comments and public input really do matter despite all the cynicism in the world about American politics.
But you may be thinking, 'But it is too late for me to attend Hill Day 2011, maybe I'll do that next year...'  That is a great start but I am telling you it is not enough to put this off.  You can actually act now and here are just a few ways you can help amplify the voices tomorrow for the future of hospice:

• Write your Congressional representative (using NHPCO's CapWiz system is easy)
• Donate to the Hospice Action Network (it takes staffing to make this all happen)
• Pledge with a friend or colleague at work to do some of the items in this list
• Follow @HospiceAction on Twitter and re-tweet and reply to posts with #HillDay11
• Friend Hospice Action Network on Facebook and engage/support/like their posts (Let's see if we can get them over 5,000! They are at 4,583)
• Make a meeting today with your local government representatives to make sure they know hospice matters
• Ask your company what they are doing to encourage staff to participate in advocacy
• Ask your hospice and palliative peers what you are all going to do for Hill Day 2012
• And you can watch the pep rally/kickoff for Hill Day 2011 on Ustream live at 9am ET to get in on the excitement of legislative advocacy!

And in the Pallimed spirit of asking you to do things I would do myself...

I already sent a letter to Pat Roberts and Jerry Moran (Senator from Kansas) and Kevin Yoder (Congressman from my District); Donated $30 to the Hospice Action Network; Told you about HAN; Have followed HAN on Twitter and RT a #HillDay11 post; Friended on Facebook and engaged; And pledging to you to talk to my company, local peers, and local government in the next month about hospice advocacy.  (
Total time 15 minutes.)

Now imagine if the nearly thousands of hospice and palliative care staff out there would all do any part of this.  What an impact that could be!

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MedPAC (Medicare Payment Advisory Commission) released a brief and a presentation from a November 5th meeting from a session covering frequency of hospice visits and extrapolating that information to the Medicare reimbursement structure for hospice agencies.  Since most hospice agencies have a large majority percentage (around 80-85%) of patients on Medicare any tinkering of the reimbursement structure is bound to get some administrator's attention.

The fact of MedPAC examining this issue is not new for they have been doing so for the last several years.  In early 2009 they made a recommendation to increase payments at the beginning and end of a hospice stay.   The purpose was to reflect the higher care needs around admission to hospice and near the time of death.  Bloggers and organizations commented on this:

• here (Pallimed)
• here (NEJM-free full text)
• here (NAHA)
• here (About.com)
• here (Larry Beresford)
• and here (NHPCO)

Any hospice staff should read the brief and the presentation (it will take you all of 20 minutes) and many palliative care providers who are not in hospice should understand these issues on the surface at least.  Here are a few key facts from each since I have a feeling not everyone will go read it like I suggested.  (Hey, we are all busy!)

Background:

• In March 2009 MedPAC recommended increasing reimbursement at beginning and end of hospice stays (a U-shaped pattern)
• Medicare currently pays hospice in a flat per-diem, thus making long admissions more profitable
• This was based on data from VITAS a national for-profit hospice

New Info:

• Since the reimbursement recommendation was based on data from one hospice, the recommendation may not have the strongest scientific/economic foundation.
• They now have two new data sources: Medicare claims data from 7/08-12/08 & 17 non-profit hospices visit data from 10/05-09/08 

What MedPAC Found (some great graphs for this in the presentation):

• # of visits does not differ by diagnosis when adjusted for length of stay
• # of visits and visit hours are increased for short stays when compared to long stays
• Patients in nursing homes and assisted living get more visits than home patients*

The data did not make much comparison between the for-profit and non-profit data.

If you leave any comments here I will be happy to forward them on to MedPAC unless you tell me otherwise.  If you want to comment directly to MedPAC you can email them.

*At first I was surprised at this fact, but then I guess it makes sense that nursing home patients would get more visits because of the increased efficiency in seeing multiple patients in one central location.

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The National Alliance for Hospice Access issued a press release and data analysis regarding appropriate access to hospice. This is a significant issue for members of the NAHA because they are supporting reform to the current Aggregate Medicare Hospice Cap in addition to other reforms. The NAHA has voiced displeasure with lack of support from the NHPCO on NAHA positions. A more detailed comparison of the NAHA report to the NHPCO report may show some differences some may find compelling to change their mind and support the NAHA Cap Reform position.

Image by Daniele Sartori via Flickr

The main points from the NAHA data analysis include:

• 4 out of 10 hospice patients got no more than 10 days of care
• Only 16% of hospice patients get 60 to 180 hospice days, the range that improves quality and costs
• Minority access to hospice care trails access for whites by 25%

I am going to have to spend some more time comparing the NAHA and NHPCO data before I can give it a full post. Here is a link to the NAHA report and the blog post on the NAHA site.

The poll on views towards the hospice cap last week while non-scientific leaned heavily towards cap reform. Much more than I ever expected given what I have heard in conversations from peers. 214 people voted (you could vote more than once - a significant problem with the poll structure) 13 people thought the cap was fine as it is. 25 wanted to know more about it and a whopping 176 thought it should be reformed. The reason I don't think this poll was accurate is because of people I have talked to at national palliative care meetings the number is more like 3:1 in favor of leaving it be. Also of the 4,000+ hospices, the majority of them are not members of NAHA.

So what that leaves me with is the opinion that we need to have some more open discussions about what the hospice cap problem is, who is affected and what should be done about if anything. If there are enough people discussing this issue in the comments, we will dedicate some more time to the hospice cap and maybe invite representatives of the major hospice organizations to have a roundtable discussion on the subject here on neutral ground at Pallimed.

So if you want it, make some noise. It sure worked for the FDA - morphine issue.