Health AGEnda

Throwing out the baby with the bathwater? – Part II

Posted in category End of Life Care, Health Policy, Medicare



Last Tuesday, I offered some basics on hospice care in America—mostly for older people, mostly at home, and becoming standard care with 40% of Medicare beneficiaries now in hospice when they die.  I warned that the attention on supposed “overuse” and increased costs from long-stay cases may lead to an overreaction that we will all regret.

As I argued last week, the real problem with hospice is not overuse but that most people assigned to it do not get enough—recall that only 33% of hospice enrollees get the 30 days of care that experts think is the minimum effective “dose.”  The only reason I can see that we are satisfied with a less than effective “dose” is that it is cheap (16 x $143 = $2,288 for the median patient.)

I’ve felt for a long time that a reasonable policy experiment would be to relax the life expectancy requirement of people entering hospice, say from six months to nine, to try to increase median length of stay.  MedPAC, the advisory body for Congress on Medicare, argues that the drivers of excessively short stays are outside the financial and regulatory structure of the hospice benefit itself, but I think the experiment would be worthwhile and is certainly better than doing nothing.

Another better-than-nothing approach laid out in Section 3140 of the Affordable Care Act finally provides for a “concurrent hospice” demonstration that will test on a small scale the consequences of offering hospice while a patient is still in curative treatment.  Research supported by The Robert Wood Johnson Foundation (reported in 2002!) suggests that models permitting a more gradual transition from full-on curative care to hospice care result in substantial cost and quality benefits.  But with all the work dumped on the Centers for Medicare and Medicaid Services in health reform, I wouldn’t hold my breath for this demonstration to get going.

I would also very much like to see efforts to give hospitals and physicians some incentives to get patients into hospice with more time to benefit as opposed to our current fee-for-service, more for more system (see “A Disappointing About-Face” ). I recall the case of my late Aunt Janet, who, as soon as she had had expensive brain surgery, radiation, and rehab for her brain cancer, was immediately certified for hospice.  And I can’t help but recall what Upton Sinclair said: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”  Perhaps Accountable Care Organizations can align incentives so that patients get all the care they need when they need it without artificial distinctions between curative, palliative, and hospice care.

But what Medicare has done, instead of addressing the short stay issue, is implement a new process for hospice: very formal recertification for those surviving past six months, including a physician sign-off and an in-person visit from either an MD or a Nurse Practitioner before that sign-off.   The thinly disguised intent is to make legal accountability clearer and scarier and to put an obstacle in the way of long-stay patients.  From the hospice agency perspective, recertification visits are considered part of administrative responsibilities and aren’t billable, adding to overhead costs without a change in payment rates.

I do recognize that fraud and abuse exist in health care and agree that Medicare has to address the issue.  A few recent headlines provide some dramatic examples of intentionally criminal behavior, such as this $200 million fraud case in South Florida unrelated to hospice care.  However, Medicare’s new hospice recertification procedure seems a weak response to criminal fraud and an intentionally burdensome and unclear regulatory approach that certainly drives up costs and has a real risk of discouraging legitimate service use.

A more sensible program modification being considered is the so-called “U” shaped plan for hospice daily payment.  The observation is that real costs of hospice care are high at the beginning (with care planning, mobilizing durable medical equipment, and implementing plans), lower in the middle (steady state – especially in long-stay cases), and high again at the end (when active dying may require new services or a revision to the care plan).  Therefore, a reduction to the daily payment rate for the middle period would reduce the “excess” profitability of long-stay, low-intensity clients.

I still think this notion still misses the point.  More and more micro-management of how care is delivered and how it is paid for is the reverse of what Medicare administrators have stated they want: to identify measures of quality of care and seek value for the health care dollar by permitting providers more flexibility.  The reality is that more and more people will be dying of things other than cancer that have unpredictable courses and variable needs.  We need to go back and design a benefit and a model of care that will serve people with these needs.  Larding on more and more layers of regulation to a benefit that is just not well-suited to their care is not the answer.


7 thoughts on “Throwing out the baby with the bathwater? – Part II

  1. While I agree with the overall arguments of this great 2-parter, I would point out the other rationale for the “face-to-face encounter” recertification requirement, which is to encourage greater involvement by physicians and nurse practitioners in hospice patient care. MD/NPs can bill for other medical services delivered during the “face-to-face” and it’s possible that we’ll see even better team care as a result. I did a quick scan of our friends at the GeriPal blog to see if the issue has been discussed. Check out one nurse care manager’s perspective from earlier in the year:

  2. Chris, thanks for a wonderful presentation of relevant issues.   Given the current interest in decreasing time in the hospitals for those with complex, chronic diseases,  the success of the hospice benefit is a chance to learn more about the process.  Rather than focusing on those situations where hospice is “overused”, I prefer your focus on the more relevant problem of “underuse.”  It would be nice to find a way to “titrate” the degree of home-based services with institution-based services.  Palliative care services currently occupy this “space” for many patients, but even greater flexibility, and appropriate financial incentives, for different arrangements is needed.   Wonderful description of the relevant issues — thanks.  

  3. Thank you, Chris, for an excellent two-part post in response to recent misleading media alerts about hospice fraud.  I have been a hospice social worker for over 20 years and have felt frustrated by Medicare’s increasing scrutiny of hospices to make sure they’re not committing fraud.  The four non-profit hospices that I’ve worked for – 2 in CT, 2 in MD – are working hard to effectively meet the needs of patients and families while conscientiously complying with ever-tightening Medicare regulations.  Ripping off Medicare is truly not one of our goals.   I wish they’d go after the big fish who are committing Medicare fraud and give us small fish a break.  I agree with you that the real problem is underuse of hospice care, not overuse.  

  4. Chris, your two part blog series on hospice has been outstanding. It is clear that even if people are more likely to be using the hospice benefit that unlikley to recieve hospice for the minimally recommended 30 days. While relaxing regulation around the qualifications may be one approach, we desperately need to address the communications between clinicians and patients. Research that appeared in the Jan 11 2010 issue of Cancer looked at survey results from 4,074 doctors who took care of cancer patients (Physician factors associated with discussions about end-of-life care). The survey asked these providers to imagine they were meeting with a patient who had only four to six months to live, but felt well. The doctors were asked when they would discuss prognosis, and some end of life decisions such as whether the patient wanted resuscitation or hospice care. How did the oncologists fare? Not well. Although 65% said they would talk about the prognosis (imagine that 35% wouldn’t be informed), less than half would discuss resuscitation (44%) and a paltry one-quarter would discuss hospice (26%). Most of the doctors said they would wait until the patient felt worse or there were no more treatments to offer. This is a strong indication that changing physician behavior is needed if we are to rightsize hospice utilization. I am pleased with ASCO’s recent recommendations to address communications with seriously ill patients.

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