Hospice status survives and advances in Medicare reform legislation

New law will offer some immediate benefits

While the debate over Medicare reform swirled around how to provide relief to senior citizens burdened by the high cost of prescription drugs, care for the dying was quietly improved. Once the massive Medicare reform bill was signed into law Dec. 8, hospices became the recipients of changes that industry experts say will help increase access to hospice care.

President Bush signed the Medicare Prescription Drug Improvement and Modernization Act of 2003 amid ceremony and fanfare to showcase Medicare’s new prescription drug benefit, and to hold up the sweeping change as a feather in his administration’s cap. For hospices, though, there was celebration of the fact that Medicare left the hospice benefit largely intact and preserved its status. That means access to hospice services will not be negatively affected by other changes in the Medicare program.

The latest Medicare legislation includes a managed care program, as well as changes to traditional Medicare. Just as hospice care was treated under previous and current Medicare managed care programs, the Medicare Hospice Benefit will continue to be treated as a "carve out." Under traditional Medicare, the hospice benefit remains a distinct service.

"It’s a step in the right direction," says Naomi Naierman, MPA, president and chief executive officer of the American Hospice Foundation in Washington, DC.

These industry-supported measures ensure hospice access for Medicare beneficiaries regardless of the Medicare program they select, says Jon Keyserling, vice president of public policy for the National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA.

Unlike the drug benefit, which doesn’t take effect until 2006, provisions aimed at strengthening the services hospices provide to dying Americans and their families became effective when Bush signed the legislation into law. Under the provisions, Medicare-certified hospices will be allowed to contract with other Medicare-certified hospices for core services. According to the NHPCO, this will help hospices provide core services when faced with situations such as unexpected periods of high patient census or staffing shortages. This new provision was included to address two potential service gaps: care for the traveling patient and care requiring specialized nursing services.

Provisions enhance flexibility

The NHPCO-supported provision allows hospices to contract for highly specialized nursing services, such as infusion therapy specialists, giving hospices flexibility to meet the unique care needs of hospice patients.

Under old Medicare regulations, traveling hospice patients — such as those who live with out-of-state family members for a portion of their illness — would have to be discharged from their current hospice and then admitted to the hospice in the area they are visiting. When the patient returns home, he or she would have to be discharged from the hospice in the out-of-state location and be readmitted to the original hospice. Now, the hospice simply contracts with a hospice at the patient’s destination, avoiding the need to temporarily discharge the patient and preventing loss of control over the care the patient receives.

Hospices also can contract staff to provide specialized nursing services, but this comes with a catch: Hospices will have to prove that employing a nurse for these services is not cost-effective. Specifically, hospices will have to show the specialized service is not one routinely provided by the hospice. These provisions follow a temporary measure issued by the Centers for Medicare & Medicaid Services (CMS) in September 2002, which allowed hospices to contract for core nursing services rather than hire a nurse to provide services. The move was made to address the nursing shortage that still afflicts all of health care.

Red tape aplenty

However, CMS’ sympathy for the plight of hospices doesn’t come without its share of red tape. To qualify for the exemption to the core services provision, a hospice is required to provide written notification to its state survey agency when the nursing shortage has become so severe that the hospice is unable to hire its own nurses. In addition, the hospice must estimate the number of nurses it will need to employ under contract. This notification should do the following:

  • Give an estimate of the number of patients that the hospice has not been able to admit during the past three months due to the nursing shortage and the current and desired patient/ nurse ratio for the agency.
  • Provide evidence that the hospice has made a good-faith effort to hire and retain nurses, including:

— copies of advertisements in local newspapers that demonstrate recruitment efforts;
— copies of reports of telephone contacts with potential hires, professional schools and organizations, recruiting services, etc.;
— evidence that the hospice’s salary and benefits are competitive for the area;
— evidence of any other recruiting activities (e.g., recruiting efforts at health fairs, educational institutions, health care facilities, and contacts with nurses at other providers in the area);
— an ongoing self-analysis of the hospice’s trends in hiring and retaining qualified staff.

  • Demonstrate that it has a training program in place to ensure contracted staff are trained in the hospice philosophy and the provision of palliative care prior to patient contact.
  • Provide assurance that contracted staff are providing care that is consistent with the hospice philosophy and the patient’s plan of care.
  • Show that contracted nurses are used to supplement the hospice nurses employed directly. Contracted nurses should not be used solely to provide the continuous nursing level of care or on-call service.
  • Show that the hospice is expected to continue its recruitment efforts during the period when it is contracting nurses.

Nurse practitioners not employed by a hospice will now be allowed to continue following their patients who elect hospice care. This provision addresses the disruption in the continuity of care when a patient elects hospice and must give up the staff that has cared for him or her for the majority of the patient’s illness. Also, the inability to continue the patient/nurse relationship has been a barrier for many people who would benefit from hospice care.

Under the old rules, physicians were the only exception to the requirement that patients, upon entering hospice care, give up services not related to hospice care. This change closes the gap that can occur when nurse practitioners play a role more prominent than a physician. "In rural settings, a nurse practitioner is often the only caregiver for miles around," says Keyserling. "Now the disincentive of losing a caregiver is no longer there."

Nurse practitioners, like a patient’s physicians, are allowed to continue providing visits and assist patient management. The nurse practitioner, however, cannot certify that a patient is hospice-eligible, and payment for nurse practitioner services is separate from the hospice per diem.

Another change is that Medicare will now allow for a one-time hospice consultation service for terminally ill Medicare beneficiaries beginning in January 2005. The service, which must be provided by a physician who is either the hospice medical director or an employee of a hospice program, would involve an evaluation of the individual’s pain and symptom management needs, counseling regarding end-of-life issues and options for obtaining care, and advising the individual regarding advance care planning. "It provides a knowledgeable source to a patient so the patient can make an informed decision," Keyserling says.

The education consultation provision provides hospices with another opportunity to reach out to patients, and it also becomes a source of revenue, albeit a modest one. How the visit will be coded using CPT codes for Part B services is yet to be determined, but it will likely come out of the evaluation and management section of the coding manual. "It gives patients a chance to consult with a hospice physician without having to commit to electing the hospice benefit," says Naierman. "Any opportunity to reach out and talk to people about hospice will inevitably increase access to hospice."

CMS will establish three rural demonstration sites that will provide hospice care in residential facilities of 20 beds or fewer for beneficiaries who are unable to receive hospice care in their home. The demonstration sites will provide care inside the facility and not in the community. This demonstration project will be conducted over a period of not more than five years.

The provision calling for demonstration projects does not have money attached to it, but it grants a waiver to participants for the 80/20 Rule, which requires inpatient care not to exceed 20% of the care the hospice provides. In at least one of the sites, an inpatient facility will act as a central site for care, allowing patients in remote areas who are without caregivers to be cared for in a hospice setting.