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Hospice Meds and Medicare Part D


If you are a hospice provider there is a good chance that there is no new information in this blog for you.  If you are in home care, pay close attention.  This isn’t as unrelated as you think.

The Hospice CoPs were updated for 2014.  There were a couple of minor changes to the reporting system and some rate changes and page after page of references to the original 1983 hospice benefit.  After 20 years of paying for hospice care to providers who were clueless about the complexity of diagnosis coding, Medicare began enforcing ICD-9 coding according to regulations.

Medicare also stated in that rule that the hospice benefit was to cover all care for the terminal illness and related conditions.  There has been a lot of debate on what is or is not ‘related’.

Medicare has some strong opinions on the relationships among illnesses and has now offered the guidance that Hospices should pay for pretty much all medications the patient needs.  They have identified 12M and change in analgesics that were billed to Part D for patients receiving the hospice benefit. However, if the patient wants a medication that the hospice does not feel is reasonable and necessary, the patient is free to pick up the tab.

I have no reason to believe that Medicare will stop at analgesics (their catch-all term for all pain meds – likely includes Ora-Jel for a toothache present before the terminal illness began).  The March Med-Pac report was even more critical (in a misguided sort of way) about the role of Hospice.

This leaves us with a huge gap, folks.  On the one hand there are imminently terminal patients who should be in hospice and on the other side of the spectrum there are home health care agencies who are tasked with providing short term intermittent care.  There is no palliative care benefit.

These are very narrow margins of white and black on opposite sides of a huge grey area.  Consider the following patients:

    • Mr. Jones, now 50, has been diabetic since his late 30’s.  He also has COPD and two years ago he had a heart attack which left his left ventricle almost useless.  He got tired of all the trips to the ICU where he was intubated and heat caths, etc., and just wants to go home and die.  Until such time, he would also like to breath.  Lasix may keep the symptoms of heart failure at bay but what about the inhalers for COPD?  What about his blood sugar?
    • Ms. Smith has rheumatoid arthritis that responds very well to IV medications once a month.  Her Orenica costs in excess of $21,937.50 per year.  (Ideally, she will only need half that much).  She is admitted to hospice with a terminal diagnosis of brain CA.  Do you continue to provide the Orenica?  What if her intention is to refuse narcotic pain relief for as long as possible because she wants to be alert to visit with her family?

The first patient really illustrates the grey area.  Why continue diabetic treatment for a terminally ill patient?  Can you really make yourself believe that a long standing history of diabetes was not related to the heart attack?  What if extremes in blood sugars cause him to be confused and uncomfortable?  What if the ‘treatment’ for COPD is the only way the patient can be comfortable?

The second patient is very clear.  If I had choice to continue to receive a medication that kept me free from pain and alert or elect the hospice benefit which relied on narcotics, I would not elect the hospice benefit. But, what if the patient met the eligibility requirements for the hospice benefit?  Are they stuck with a drug problem they cannot afford?

This is going to amount to a lot of patients who need care returning to home health if they are lucky enough to have a skill.  Those who do not have needs that warrant skilled home health services will be left out in the cold.

If you think I am merely creating drama or resorting to my favorite sport of Alarming Providers, read the quotes below from the December letter from CMS ‘clarifying’ their position regarding hospice meds and Medicare Part D.

“…..the original intent of the Medicare Hospice Benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provided pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting.”

“Thus, when we refer to “pain and symptom relief”, or “palliation and management of the terminal illness and related conditions”, this encompasses all medical supplies and drugs needed to manage all the patient’s health conditions related to the terminal prognosis, to minimize symptoms and maximize comfort and quality of life. The focus is not limited to pain medications or a narrow definition of palliative care, but is broad and holistic.” Now they decide to be holistic?  December of 2013? 

“Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide because it’s not reasonable and necessary for the palliation and management of the terminal illness and related conditions . The cost of  such a medication,which is not reasonable and necessary for the management of the terminal illness or related conditions,would be a beneficiary liability.”

The letter goes on to state that the hospice provider must give the patient an ABN and the patient can appeal the process. Does anyone else see the flaw in that process?

Review last week’s post about the indefinite leave of absence by the Administrative Law Judges.  While it is true that beneficiaries can still appeal, the life span of the average hospice patient is less than 25% of the average wait time for an ALJ hearing.

I guess the ‘holistic’ part only includes physical, spiritual and emotional needs.  Financial needs are bequeathed to the survivors – you know, so they will have a reason to go living on after the death of a loved one.

What a fun year this is going to be,

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