Published: August 06, 2007 09:52 am            

Hospice care threatened by obscure Medicare rule

ADA — Victory Home Health and Hospice and Indian Territory Home Health and Hospice serving dying people throughout Southern Oklahoma are two of hundreds of American hospices facing devastating consequences as the result of an obscure rule in the Medicare hospice benefit. Hospices in at least 25 states are being asked to refund hundreds of millions of Medicare dollars they were paid to care for hospice patients that are taking too long to die, according to the Centers for Medicare and Medicaid Services.

"Our goal as a health care provider has always been to provide the best care for our patients and their families. With the current hospice cap in place, it forces agencies like ourselves to put a dollar amount on patient care. That is not in the best interest of the patients or their families." said Jayson Northcutt, Chief Operations Officer, Indian Territory Home Health and Hospice.

The Medicare program pays a daily rate to hospices to care for dying patients in their homes, hospitals or long-term care facilities. Patients must meet Medicare's eligibility standards and be certified by a doctor as terminally ill with six months or less to live. Hospices provide nurses, medication, equipment, chaplains, and social workers along with bereavement counseling for family members.

“Our mission in hospice care is to provide compassionate, quality hospice and palliative care to the terminally ill patient and their families. We are entrusted to fulfill our mission professionally and efficiently. We continue to provide comprehensive, competent, quality end of life care by providing physical, social, psychological and spiritual care bringing dignity to one's last journey. The hospice cap has placed a huge burden upon our hospice and many others paying back Medicare for their mistakes of misfiguring the cap for 2003 and 2004 and many of the hospices already having a pay back for 2003, 2004 and 2005. We are still saying yes to any and all patients, but the payback of the cap makes us really watch our admitting process and not admit a patient too soon. Therefore, we have many patients dying in 1-7 days. We don't have the time to do our work as a hospice. We need Congress to make much needed changes to the Medicare Cap. You see, when Congress opened access to non-cancer diagnoses and at the same time opened hospice to unlimited days of hospice care in 1998, they forgot to make a difference in the cap. So it has been the same since 1984,” said Joan Weems, RN, CWS, Owner/Administrator, Victory Home Health and Hospice

Medicare caps average per-patient benefits for each hospice at about $20,000. Hospices that exceed the average are required to repay the difference to Medicare. From 1982, when the hospice legislation was passed, until 1998, few hospices hit the Cap; most hospice patients had cancer and stayed a relatively short time in the benefit. In 1998, Congress changed the law so that terminally ill non cancer patients, who have somewhat unpredictable periods of decline, could take advantage of hospice care. Medicare developed objective criteria for each non cancer diagnosis to define when a patient would be eligible for the benefit. Under current law patients are entitled to remain in hospice care as long as they meet Medicare's objective eligibility requirements.



In a September, 2000 letter to hospices, Nancy-Ann DeParle, then Administrator of the Health Care Financing Administration (HCFA), wrote, “There is a disturbing misperception that hospices and beneficiaries will be penalized if a patient lives longer than six months. Nothing could be further from the truth.” She continued, “Let me be clear. In no way are hospice beneficiaries restricted to six months of coverage. There is no limit on how long an individual beneficiary can receive hospice services, as long as they meet the eligibility criteria.”



The changes in the law worked. The share of hospice patients with non cancer diagnoses increased from less than 10 percent of all hospice patients to over 50 percent. However, Congress neglected to remove or modify a Cap on the hospice provider that was part of the 1982 law. As eligible non cancer patients stay longer in hospice care, many providers are reaching their Cap and must refund the Medicare dollars they spent on patient care.



Hospices are hitting the Cap at an escalating rate. In 2004, hospices in 15 states were asked to pay back about $100 million. For 2005, estimates suggest that hundreds of hospices in at least 25 states will be asked to repay hundreds of millions of dollars.



Recently, Victory Home Health and Hospice and Indian Territory Home Health and Hospice joined other hospice providers in the National Alliance for Hospice Access, (NAHA) a grassroots coalition of independent hospices who are interested in ensuring that hospice services remain available to those who are entitled to receive Medicare covered end-of-life care. NAHA was founded by Lois Armstrong and David Daucher, partners in Sojourn Care, an Oklahoma hospice that first hit the Cap in 2005.



“Hospices cannot 'manage the Cap' without rationing access to care,” said Armstrong, who serves as President of NAHA. “Good hospices care for all eligible patients who elect the hospice benefit for however long they remain eligible. The Cap means that these providers face devastating financial consequences, even bankruptcy.”



NAHA has a single goal, a legislative correction to the flawed law. “Providers feel forced to make terrible choices such as limiting the admission of non cancer patients or discharging patients who “live too long” whether they remain medically eligible for hospice or not,” Daucher said. “Such choices deny patients the access to hospice care that Congress specifically intended. NAHA hospices are working with Congress now to find to legislative solution to this problem that is hurting patient access to hospice care.”



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