Non-cancer review policies still incite controversy

Do chart reviews predict future denials?

The controversy over turning National Hospice Organization (NHO) "Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases" into local medical review policies for fiscal intermediaries to use in determining Medicare hospice eligibility refuses to die. (See Hospice Management Advisor, January 1998, p. 5.) The Ohio, New York, Texas, and Carolinas hospice organizations, along with Vitas Healthcare Corporation, Hospice of the Florida Suncoast, and others are studying the policies, applying them to retrospective chart reviews, and considering strategies to address potential barriers to hospice access.

The medical review policies, modified by fiscal intermediary medical directors from NHO's original guidelines, have already been implemented in slightly different forms by Medicare Health Care Services Corporation in Illinois and Palmetto Government Benefit Associates in South Carolina, with Wellmark in Iowa soon to follow. However, while some providers are anticipating demands by intermediaries for increased paperwork to justify prognosis for patients who don't strictly meet the criteria, at press time there were no reports of actual denials based on the policies.

70% of `ineligible' patients died in one month

Initial data from the hospice associations' retrospective chart reviews suggest that a significant portion of non-cancer patients admitted to hospices and dying within 210 days (often far sooner) would not have met the new medical review criteria at the time of hospice admission. For example, preliminary data from Ohio indicate that over one-fifth of non-cancer admissions would not have satisfied the policies, and another fifth would have lacked necessary clinical data, yet 96% of these patients actually died in less than six months and 70% of them died in less than one month. "It would seem the local medical review policies still need a great deal of review and adjustment," observes Ohio Hospice Organization executive director Bernice Wilson, RN, MS.

Gretchen M. Brown, MSW, president and CEO of Hospice of the Bluegrass, Lexington, KY, adds, "These criteria are more stringent [than the NHO guidelines], and require more backup information. Getting that information has a cost and becomes a new standard of practice for hospice, not contained in the regulations." For example, tests to determine blood gases are required for certain cardiovascular diagnoses in the absence of recent medical records. Hospital charts often contain these data, but hospices historically have had great difficulty obtaining hospital chart data at the time of admission.

J.R. Williams, MD, chief patient care officer for Vitas Healthcare Corporation in Miami, FL, reports that in a study of 160 non-cancer patients at 10 different Vitas hospice sites - all of whom would have qualified under NHO's guidelines - 43% would have been found ineligible for hospice care under the medical review policies. Vitas is pooling its data with several state hospice organizations, and plans to share the results with the Health Care Financing Administration (HCFA). "Some providers have raised so much objection in the last couple of months that there's been some awareness by HCFA that providers are not happy," Williams says.

Throughout the controversy, NHO has emphasized to its members that it did not intend for its advisory guidelines to be used in making coverage decisions. Outgoing NHO president John J. Mahoney, in his last week on the job in late January, sent a lengthy letter on the issue to Williams with copies to concerned state hospice leaders. In that letter he outlines the regulatory and public policy context in which the guidelines became medical review policies. Mahoney emphasizes that he does not believe the policies would be used by intermediaries as a "front-end audit/edit process at the point of admission" for all non-cancer patients, in part because it would be prohibitively expensive for them to do so.

"Frankly, I do not know if these policies are fatally flawed or very nearly perfect. I am, however, relatively certain that a process involving retrospective chart reviews of patients not specifically admitted under these policies will not convince anybody but ourselves of the potential problems associated with the policies," Mahoney states.

NHO's executive committee was scheduled to meet in mid-February to explore the next steps to be pursued with HCFA, reports new NHO chairperson David A. Simpson, MA, LSW, executive director of Hospice of the Western Reserve in Cleveland. "We're hearing a variety of perspectives from providers around the country. Some are not having much difficulty with the policies and some are having some difficulty, while others are anticipating a great deal of trouble."

"I've heard the rumblings, and it's a continual puzzle to me," responds Richard Baer, MD, associate medical director for Medicare Health Care Service Corporation, which, coincidentally, has notified HCFA of its intention to give up its Medicare contract. "We had heard hospices complain that everybody was dying within 10 days of admission. Providers are afraid of anything they intuit could inhibit access to hospice, and they're afraid of the concrete language in the policies," Baer suggests. He still says the medical review policies, as revised with provider input, will accomplish what they're supposed to, which is "to identify patients appropriate for hospice admission."

"We certainly need to take the panic out of this issue," adds Diane H. Jones, MSW, ACSW, executive director of the Hospice Association of America. "Providers should not let themselves be so scared they err on the side of limiting access. I don't think the policies are all that bad, but there's no guarantee they will be used the way Dr. Baer envisions in every case." Jones recommends that the policies be modified to allow for hospice professionals' clinical judgment, that HCFA commit to at least annual review and updating based on new research, and that the government also study what happens to patients who are discharged from hospice because their condition stabilized.