More on hospice reform

The WaPo had an interesting article (leaving aside the needlessly sensational headline) noting that 1 in 6 hospices that served 50,000 Medicare beneficiaries who died provided no continuous home care (extra care when patients have very high needs implemented by hourly payment increases, typically just before death) or Inpatient hospice care (again, a higher acuity setting; most get hospice in the home, but there are facilities).

The worry is that some hospices are either (1) not adequately serving some patients, or (2) that they are enrolling patients into hospice who may not fit the parameters of the benefit. A few thoughts on this, which is another piece of information that is likely to help us creep toward some consequential reform of the hospice payment approach in Medicare.

  • This statement from the National Hospice and Palliative Care Organization (NHPCO) is the clearest statement I have seen from them saying that hospice providers who are unable to deliver the entirety of the hospice benefit package in Medicare shouldn’t be allowed to do so in a partial manner. The first sentence of the statement sets the tone, and this statement is a subtly important public moment that will enable more aggressive change:

“There are two kinds of hospices in America: the ones that get it right, and those that should be out of business. “

  • On hospices not ever delivering inpatient hospice care, I have heard some smaller, often rural hospices lament that larger inpatient facilities will not provide them with a contract that lets them avail themselves of the inpatient unit. There can be similar issues with hospital based inpatient units as well as with nursing homes. And if a state is a certificate of need state, the hospice cannot build a facility. The hospice industry is ripe for cosolidation, and (lack of) access to inpatient hospice facilities in some areas will help to drive it, especially with this increased attention.
  • The groups of hospices who are not providing any continuous home care hospice coverage is a trickier group. First, it seems unlikely, but not literally impossible, that a hospice would never have a single patient needing around the clock care in the last few days or hours of someones life. This raises quality concerns for patients in a given hospice, and also for those who may be unserved due to inability to meet patient needs. This is pure hospice policy. Second, some hospices in this category may essentially be providing a back door long term care (LTC) benefit. And backdoor LTC being provided via the hospice benefit in this manner could be more valuable to patients and families than anything else that Medicare is paying for; however, that is not what the hospice benefit regulations allow.

We need to sort through these issues and reform the hospice payment and enrollment system in the Medicare program. Following the rules is important. We need to also listen up for signals that the rules may need to be changed. When teaching Intro to the U.S. Health System at Duke from 1999 to 2003, I used to say the biggest hole in the benefit package was prescription drugs and LTC. Now I say it is LTC.

The lack of a coherent LTC system in the U.S. has spillover effects into all sorts of Medicare policy, including hospice (e.g, long stays more likely debility/dementia). It would be better to address these head on.

About Don Taylor
Professor of Public Policy at Duke University (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute). I am one of the founding faculty of the Margolis Center for Health Policy, and currently serve as Chair of Duke's University Priorities Committee (UPC). My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

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