Behavioral changes might be biggest challenge in '09

Fiscal responsibility, more scrutiny to affect

Change is never easy, but the toughest type of change is behavior or culture change within a hospice, says Susan Levitt, executive director of CNS Home Health and Hospice in Carol Stream, IL. As hospices face more regulation, fiscal responsibility will become an important part of every staff member's mindset, she says.

Court dismisses lawsuit against CMS

NHPCO evaluates other options

The lawsuit filed by the National Hospice and Palliative Care Organization (NHPCO) to block implementation of part of a final Medicare rule designed to phase out the budget neutrality adjustment factor (BNAF) has been dismissed.

The U.S. District Court for the District of Columbia dismissed the lawsuit on procedural grounds without examining the substantive merits of NHPCO's claims. The final rule was promulgated by the Centers for Medicare & Medicaid Services (CMS), and the lawsuit was filed against CMS and the Department of Health and Human Services (HHS).

The ruling was based on the court's view that, before it addresses the merits of the arguments presented in NHPCO's lawsuit, CMS first should be given the opportunity to consider those claims in an administrative appeal by affected hospices.

"While we had hoped that the court would be able to make a decision to settle the suit now, we do understand that the court must allow the government the appropriate process for the case," noted Jonathan Keyserling, JD, executive director of the Alliance for Care at the End of Life and vice president of public policy and counsel for NHPCO. "However, NHPCO and the Alliance for Care at the End of Life will continue to aggressively work to stop what are essentially cuts to hospice's reimbursement rates. This includes ongoing efforts to rally Congressional support for hospice."

"Hospice staffs are made up of devoted, caring people who are passionate about the value of hospice," Levitt says. "Now, we have to tell these staff members that they can't make a visit just because it feels right."

Making those "Kumbaya" visits, as Levitt calls them, might be good for the family and might make staff members feel like they are doing a good thing, but with the Centers for Medicare & Medicaid Services (CMS) collecting data, implementation of a hospice prospective payment system (PPS) based on data and standardized care might not be far behind. "We won't have the luxury of making visits without a reasonable clinical reason for the visit," she explains.

PPS: At least 2 years away?

It took several years to develop home health PPS, but it won't take as long to develop and implement hospice PPS because lessons learned in home health can be applied, she says. "I hope that hospice PPS is at least two years away because hospices will need that length of time to change the culture of their agencies," says Levitt. "Staff members and managers will need to change the way they approach their jobs."

Because hospice managers do not typically have an operational background, it is important that they begin now to learn more about the financial side of hospice and about performance improvement, she suggests. "Performance improvement activities have not been a focus for most hospices, so I think that designating a staff person as your performance improvement coordinator is important," says Levitt. "If the hospice can afford it, an individual who focuses on performance improvement will be able to become an expert in the process and ensure that projects comply with the CoPs [Conditions of Participation]."

Staff members and managers also will have to be ready for more oversight by CMS, says Jonathan Keyserling, JD, vice president of public policy and counsel for the National Hospice and Palliative Care Organization. "The Office of the Inspector General has found that in some states hospices go 10-14 years without a survey," he says. "This is too long a period of time, even for the most responsible providers." Regardless of how well a hospice is run, there is always room for improvement, he says. "Even the best practices need tuning up periodically," Keyserling says.