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Regulatory changes top list of 2009 challenges
PI activities, data collection, frequent surveys
The year 2009 will represent a year of change for hospices with new conditions of participation, greater scrutiny of claims, and new requirements for data collection. What is not known is how the economy, along with sociological and political changes, will affect the industry.
Political changes and the new administration might signal a focus on uninsured and underinsured adults as well as children, says Jonathan Keyserling , JD, vice president of public policy and counsel for the National Hospice and Palliative Care Organization (NHPCO). If President-elect Obama is able to implement changes that affect coverage of Medicare and Medicaid patients, similar changes will be seen in the private sector, he predicts.
As health care reforms are evaluated, hospice can be used as an example of integrated care model, Keyserling says. "We have 30 years of experience of providing care coordinated among different providers," he adds.
Susan Levitt , executive director of CNS Home Health and Hospice in Carol Stream, IL, says, "I'm not sure that a new administration means many changes for hospice because there is so much competition for Medicare dollars to support new programs." The change that is definitely coming is related to new regulations that hospice managers learned about in 2008, along with more regulatory changes that should follow quickly, she says.
"Hospice managers have not had to face significant regulatory changes in 20 years, and there are many organizations that are not ready for change," Levitt admits. "We saw a good example of how unprepared many hospices are in July 2008 when we had to begin submitting visit data." Hospices that are affiliated with a home health agency, or hospices with managers that have a home health background, fared better in July and will be able to prepare for changes more easily because of the constant changes home health has faced in recent years, she says.
"Hospice managers that had no experience with reporting visits had to find ways to create reports and collect data that had never been collected," Levitt explains.
Meeting several requirements of the new conditions of participation (CoPs) will be a struggle for many hospices, she says.
"Measuring quality in hospice care is important, but it differs from home health because the patient's outcome in hospice is always death," she says. The performance improvement requirement in the COPs has some hospice managers asking themselves what to evaluate and improve upon, Levitt says. Improving the quality of care will require hospice staff members to evaluate clinical issues such as pain control, as well as education and family support, she adds.
Hospice rate reform will be a priority for the Centers for Medicare & Medicaid Services (CMS) in upcoming years, and the Medicare Payment Advisory Committee (MedPAC) recommendations should be watched carefully, suggests Keyserling. CMS has begun and will continue efforts to collect data from hospices to develop a reformed payment system, he says. "I hope that as we move forward, CMS will wait until there is enough data to develop a fair payment system," Keyserling says. "To move forward without complete data would be irresponsible."
The economy and budget concerns will create intense pressure on all health care providers to protect their reimbursement, he says. Associations such as NHPCO are taking steps to monitor and take action when needed. In fact, NHPCO filed a lawsuit to block implementation of a CMS rule that would reduce the hospice wage index and cut payments to hospices. Although the lawsuit has been dismissed, NHPCO and member hospices are evaluating other options to protect reimbursement, he adds.
Another effect of the economy will be fundraising for hospices, says Levitt. While large donations and grants still might be available, her hospice is seeing a drop in memorial gifts, she says. "This may also be due to a shorter length of stay for patients as they are referred later to us, so that they don't develop the same relationship with us as families that we serve for longer periods of time," Levitt says.
The downside to lower levels of giving will be the expected increase in requests for charitable care, she notes. "Our charitable care is completely funded by donations; so, if we receive fewer gifts, we won't be able to support as many patients," Levitt explains.
A positive change in the health care industry will be the growth in palliative care programs, says Levitt.
"We have a palliative care program that is separate from our hospice program, but benefits both our hospice and home health program," she says.
Hospices ideally are positioned to provide palliative care services to patients that are diagnosed with a potentially life-threatening condition but still are seeking curative treatment, Levitt says. "It is necessary to set the program up separately, with its own staff and medical director, and to bill through the home health program, but hospice managers have the experience with palliative care to develop and oversee it," she says.
Hospices that don't have an affiliation with a home health agency easily can partner with an existing home health agency to handle billing, suggests Levitt. "I certainly don't recommend that anyone start up a home health agency now," she emphasizes.
The key to surviving the challenges of 2009 and the following few years will be flexibility, says Levitt. "We have to learn to adapt, and we have to learn managerial skills that we haven't needed before and that we didn't learn in nursing school," she says.