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Posts tagged ‘Hospice CoPs’

Five Things 5 Days at Memorial gets Right

Seven of the eight episodes of 5 Days at Memorial have aired and thus far it stays true to Sheri Fink’s book of the same name. So far, the Apple TV series has gotten five things that may be relevant to us absolutely correct.  I recommend that you all watch the series or read the book and then talk about it in your next Emergency Preparedness table meeting.

  1. A strong leader from your organization must be chosen before a life threatening emergency occurs because regardless of what you have done, a strong leader will assume authority.  It would be in everyone’s best interest if you approved of the person. At Memorial, Anna Pou, an EMT assumed control for both Memorial and Life Care which was an LTAC leasing space from Memorial hospital. Do you really want a doctor you don’t  know or who has no affiliation with your agency running your show?  
  2. If you are fortunate to have ample warning of a natural disaster, encourage your patients to move.  Move them out of your service area if that’s what it takes.  Lose money if necessary.  For the sake of comparison, I had an LTAC client that leased space on the top floor of a building across the street from Memorial.  Prior to the storm, they moved patients to Baton Rouge. It was expensive and most inconvenient but everyone was safe.
  3. Communication sucks before, during and after a disaster.  There is no other way to state that in a ladylike or professional manner. As soon as there is an inkling of a possibility of a disaster on its way, the employees need to call the patients and families and find out where they might be should they evacuate.  Although this information is part of the admission process, things change.  For weeks after Katrina, we were getting emails from people looking for relatives and loved ones.
  4. Plans fail.  Katrina was likely a category two storm when it hit New Orleans down from Category 4 or 5 while it churned in the Gulf.  Everyone was fine the next day.  It was around mid morning when the first trickles of water from a breached levee started to flood the street.  A city prepared for a storm ended up suffering from some of the worst flooding in history.  The generators in place to maintain power were under water. Focus on keeping your patients foremost in your plan and don’t try to anticipate how a disaster will evolve.
  5. Even though plans fail, it is important to have one.  If you work for an agency or hospice provider, be available if there’s any way possible.  Know what the plan is and if you are knocked off course by an unforeseeable event, at least you will know where you should be and can work to get back on track.  

Many of you are wondering why I am stating the obvious.  It’s because many people don’t learn.  Last year, Hurricane Ida hit and one nursing home owner, Bob Dean, thought it would be a good idea to warehouse almost 800 people in a warehouse.  It flooded and the patients were moved to a dryer area.  Most patients were side by side on wet mattresses that were touching with no room for nurses to get through.  Eight people died as a direct result and more died in the following weeks.  It is impossible to care for 800 elderly patients in a dark warehouse with no electricity or running water. Bob Dean felt he was treated unfairly when his licenses were revoked.  When that was largely rejected by the public he went on to say that he suffered from temporary Dementia.  He thinks his licenses should be restored.  Maybe if he hadn’t been visiting friends in the cool dry climate of Connecticut and been out to the unsanitary (to be kind) warehouse, he would have a different opinion.

When we live through a once in a lifetime event, we tend to believe that it is just that – once in a lifetime.  These unimaginable events are exactly that – beyond the scope of our imaginations.  All we need to keep in mind is that bad things happen and our patients come first.

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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