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Wellmark Inc. has become the first fiscal intermediary to adopt changes within its own local medical review policies (LMRPs) for non-cancer diagnoses, and removed the controversial phrase "rapid decline" in order to make the policies less restrictive and provide better direction for hospice referral or recertification.
Instead of hospices having to prove rapid decline, hospices that submit claims to Des Moines, IA-based Wellmark will simply have to prove a "decline in health status." Under the original language, terminally ill patients who did not meet the strict criteria laid out for specific non-cancer diagnoses would have to document a precipitous drop in the patient’s condition in order to admit the patient into hospice or be able to continue the benefit.
But experts pointed out that patients, especially those very close to death, often linger without showing a rapid decline in health. They argued that the language would require hospices to deny access or discharge patients who need the benefit the most.
Brad Stuart, MD, hospice physician with Visiting Nurse Association (VNA) and Home Hospice of Northern California and the author of the National Hospice Organization’s (NHO) guidelines for non-cancer diagnoses, which became the basis of LMRPs, argued that the original language was too vague. Whether the language would be restrictive depended on how fiscal intermediaries would define "rapid decline." Without a true definition of what constitutes "rapid," interpretation was open to erring on the side that would prevent patients from accessing the hospice benefit or lead to discharge of current hospice patients, he said in the May 1999 issue of Hospice Management Advisor (see cover story).
Stuart, along with the NHO, urged Wellmark and other fiscal intermediaries to revise their rapid decline policy to "clinical decline," believing that it would be less restrictive, but would still require adequate documentation on the part of hospices.
After reviewing Wellmark’s revised policy for determining terminal status due to decline in health status, Stuart was pleased with the changes.
"All references to rate of decline’ were dropped," Stuart said. "This is good news, because hospices are not required to drop patients who are not declining fast enough according to some arbitrary standard."
Karen Woods, executive director of the Hospice Association of America, agrees while characterizing the revised policy as a helpful tool for hospices. "It really gives a good education on when a patient can be admitted into hospice," she says. "It’s more concerned with looking at how to bring people into the program, rather than being exclusionary."
Chris Cody, director of NHO’s National Council of Hospice Professionals, says Wellmark’s policy represents a good template policy for other fiscal intermediaries (FI) to follow. "All of our concerns seems to be addressed, and this policy seems to be well received by providers as well," Cody says.
Cody was unaware of any other FI that has committed to adopting Wellmark’s policy and remarked that others may go in a different direction.
Wellmark’s policy establishes requirements to prove changes in a patient’s health status based on clinical variables. The FI stresses that because determination of decline presumes assessment of the patient over time, it is essential that both baseline and follow-up determinations be reported, including changes functional assessment staging (FAST), Karnofsky Performance Status or Palliative Performance Score (PPS)/Adapted Karnofsky.
"These changes in clinical variables apply to patients whose decline is not considered to be reversible due to an intercurrent illness or condition," states the policy.
Policy lists these clinical variables, ranking them in order of importance and ability to predict poor survival. Wellmark does not require hospices to prove a specific number clinical variables, but says it would consider the absence of variables at the top of the list as being less predictive of the six months or less of life expectancy.
The clinical variables are listed below in hierarchical order:
• Progression of disease as documented by symptoms, signs and test results.
• Decline in Karnofsky Performance Status or PPS/Adapted Karnofsky.
• Weight loss, decreasing anthropomorphic measurements — such as mid-arm circumference and abdominal girth — and decreasing serum albumin and cholesterol. The weight loss, however, cannot be caused by reversible conditions, such as depression or diuretics use.
• Dependence on assistance for two or more activities of daily living (ADLs), which include feeding, ambulation, continence, transfer, bathing, dressing.
• Progressive dysphagia, which includes documentation that would show difficulty swallowing, is leading to inadequate caloric intake. Documentation must include a 72-hour calorie count. Criteria can be used to claim rapid decline if dysphagia leads to recurrent aspiration.
• Low systolic blood pressure. If patient has a systolic blood pressure less than 90 when prior readings showed systolic pressure greater than 90, this criteria could be used to claim rapid decline.
• Emergency room visits. Hospices could show rapid decline if the patient is increasingly visiting emergency rooms for conditions other than those considered minor or self-limited.
• Functional Assessment Staging for Dementia. Hospices would have to prove at least one stage of decline in three months with a baseline of no less than 5.
• Pressure ulcers. Persistence or progression of Stages 3 or 4 pressure ulcers in spite of optimal achievable care, such as nutrition and debridement.
Absence: A good thing
The clinical variables set forth by Wellmark represent little change from the fiscal intermediary’s previously proposed policy. The absence of change in the required clinical variables was seen as a positive thing by Stuart.
"The text is almost exactly what we agreed on during the last conference call with all the fiscal intermediary medical directors," says Stuart. "Wellmark made no additions after our call, and did not appear to want to tighten up policies."
Yet, while the policies were not tightened, hospice providers still must follow strict documentation standards. Failure to document clinical variables to prove declining health could result in the denial of a claim in extreme cases. But the purpose of Wellmark’s policy is to monitor hospices whose patients’ length of stay consistently last longer than six months. The policy provides direction regarding admission and recertification.
"It is understood that the condition of some patients entering hospice care either stabilizes or improves due to the care received," the policy states. "In such situations, if the patient’s condition improves such that he or she no longer meets Medicare’s requirement of six-months-or-less life expectancy, and that improvement can be expected to continue outside a hospice setting, then the patient should be discharged from hospice.
"On the other hand, patients in the terminal stage of their illness who originally qualify for the Medicare hospice benefit but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six months, remain eligible for hospice care."
"Hospices are required to document decline according to the list of clinical variables under Indications & Limitations of Coverage,’" Stuart explains. "This is good news for two reasons: a) The list of variables is very broad. For instance, progression of disease’ could be any sign or symptom of clinical worsening; b) This list can be used by hospice programs as prompts’ for documentation. Staff no longer has to fish around for categories of evidence to document clinical decline. It would be wise for hospices to develop documentation forms using these categories for reporting decline in interdisciplinary group meetings, progress notes, replies to ADR letters, and other applications."
The new policy was prompted by complaints since last December about vagueness of the decline language set forth in original LMRP policies. In an attempt to clear up the vague language, Wellmark, one of the largest of the five hospice FIs, set out to draft guidelines for determining terminal status due to rapid decline. John Olds, MD, FACP, regional home health intermediary contractor medical director for Wellmark, sent a draft policy of rapid decline criteria to the NHO in December for review.
While hospice advocates had little objection to the policy as a whole, it took issue with the possibility that rapid decline could be interpreted too strictly and that FIs would impose restrictive requirements to prove decline.
In a written response to Olds’ draft of rapid decline guidelines, Stuart posed the following scenario plucked right out of a team meeting at VNA & Hospice of Northern California:
An 88-year-old woman whose physical condition has been declining as a result of Alzheimer’s. She suffers from dementia, but not enough to qualify under the newly adopted Alzheimer’s LMRP criteria. Her fluid and food intake has dwindled to a point where it barely sustains life and she has withered to 69 pounds; but in the last three months, her weight has changed very little. The woman is cared for at home by her husband who is barely able to cope, despite the assistance of a home health aide who visits seven times a week.
Because the woman does not meet the Alzheimer’s LMRP requirement and the hospice would be hard pressed to prove rapid decline, she would have to be discharged from care, leaving the husband to provide the care he is incapable of providing.
"We elected to keep her on service because we expect her to die within a month or two," Stuart wrote. "We are able to document clinical decline in good faith, but under the draft criteria the patient does not come close to manifesting evidence of rapid decline. We would be compelled to discharge this patient, or risk denial of our claim — a claim that on clinical and prognostic grounds is entirely justifiable. The scenario would characterize the majority of end-stage debilitated patients for whom we provide hospice services."
In addition to having to discharge patients, Stuart believed that the rapid decline guidelines would lead to denial of claims in cases where patients who are obviously dying, but fail to exhibit enough decline during a benefit period.
Under Wellmark’s new decline policy, the above-described woman can remain under hospice care. The hospice, however, must document each of the clinical variables that apply, but would not be subject to a specific number of clinical variables to qualify their assessment of the patient’s decline in health status.
"No number of clinical variables is required to show a patient is declining," Stuart said. "Apparently, only one will be sufficient. For all these reasons, I think Wellmark’s version is beneficial to hospice. It should not be difficult for hospice programs to document decline according to these standards."