'Drive-by hospice' claims victims on both sides of the sick bed
Drive-by hospice’ claims victims on both sides of the sick bed
ORT scrutiny, reluctance by doctors add to dropping LOS
Increasingly late referrals are causing plummeting lengths of stay that are threatening hospice financially and philosophically, raising a chorus of complaints from hospices, large and small.
Anecdotal evidence from providers suggests that the already short hospice stays documented in the New England Journal of Medicine last summer1 have become even shorter as the proportion of very late hospice referrals (seven days or fewer prior to death) continues to grow. Providers have coined the term "drive-by hospice" to describe the crisis-oriented care they must now provide for very short-stay patients.
There is no clear consensus on the causes of this disturbing trend and few battle-tested solutions although experts agree that more specific data on this nationwide problem are essential. (See related story, p. 52.) But the consequences are clearly serious. Hospices are paid the same rate for each day a patient is enrolled on the Medicare benefit, but the distribution of costs is not equal, with work on the beginning days of enrollment to introduce hospice services and the final days to manage the impending death costing more than the time period in between. When those two high-expense periods overlap, with no offsetting days of comparative stability in between, the result is financial disaster.
Now with Operation Restore Trust (ORT) and focused medical review (FMR) by fiscal intermediaries closing the door to the longer stay patients that help balance these costs, hospices find themselves between a rock and a hard place. (See story, p. 53.) Shorter stays mean lower revenues and a smaller patient census, even when total admissions stay the same. The survival of some hospice programs is threatened at a time when cumulative admissions to hospices nationwide are still rising.
Short-stay patients also stretch a provider’s ability to achieve a peaceful, orderly dying experience for patients and families the very quality for which hospice is celebrated. Since the best that can be done for these patients is to manage the most pressing crises, such "drive-by" cases are likely to result in disappointment for patients and families, who are denied the maximum benefits of hospice care, and for hospice professionals, who are denied the chance to develop meaningful relationships with their patients.
John Carney, president of Hospice Inc. in Wichita, KS, reports that his agency experienced a 7% increase in admissions last year but a 17% decrease in average length of stay, which resulted in a 12% drop in revenues and staff layoffs. Hospice of Southern Illinois in Belleville saw its median days of hospice enrollment shrink from 22 in 1993 to 14 in 1996, with even lower numbers for the first two months of this year, says medical director Kent Mulford, DO. The agency’s average daily census shrunk almost in half, while referrals and admissions stayed constant, requiring significant staffing reductions. The agency also had to reorganize its network of remote workstations for staff serving its sprawling, 36-county service area, cutting back from 11 to three.
There are different ways to compute length of stay statistics, including arithmetical average (or mean) and median, the point at which there are equal numbers of cases below and above the midpoint. But one important clue from the Belleville hospice’s statistics is that its mode day, the most frequently reported number for days of enrollment in hospice, is one, Mulford says.
"I recently listened to the complaint of a family that we were involved with them for only three days," prior to the patient’s death, says JoAnn Siemsen, MPA, executive director of Hospice Caring Project of Santa Cruz County in Aptos, CA. "They had really high expectations for hospice. They kept saying, We didn’t get from you what we thought we would.’ But in three days, it’s difficult to provide all the services hospice offers. Hospice and the family both tried their best in this situation, but it wasn’t satisfactory," Siemsen says. "When we confront the doctors on cases like this, they always say, I’m sorry, but it’s the family that resisted the hospice referral.’"
"There is no question that the activities of the Inspector General are contributing to dropping length of stay in hospice," says John J. Mahoney, president of the National Hospice Organization in Arlington, VA. "But it is too easy in an environment as rapidly changing as we have to put all of the blame on one cause. We have to be careful that we don’t ignore other considerations. The answers usually are much closer to home, even though the issues are happening nationwide."
Given the urgency of the length-of-stay crisis for hospices, providers around the country have speculated about a number of possible causes.
1. Operation Restore Trust (ORT).
The high-visibility audits of long-stay hospice patients by the Office of Inspector General (see related story on p. 55), alleging that hospices have admitted thousands of ineligible patients without an obvious documented prognosis of six months or less to live, has sent a chill through the industry. Hospices have become more conservative in their admission practices, particularly with the noncancer admissions targeted by ORT and FMR. Physicians are more reluctant to make referrals, and even some patients have expressed concern that they are not dying "on time."
"Just last week we admitted a patient who died within eight hours of enrollment," says Bonnie Kosman, MSN, RN, CS, CDE, director of patient care for Lehigh Valley Hospice in Allentown, PA. "Physicians tell us they are concerned that if they admit patients too soon and those patients don’t die on time, they could be accused of fraud. One physician asked me, Am I going to be fined?’" Kosman relates.
2. Difficulties in making a terminal prognosis.
A consequence of the ORT controversy, and recent research such as SUPPORT (Study to Understand Programs and Preferences for Outcomes and Risks of Treatment), is a growing appreciation of the inherent difficulties physicians face in making a prognosis of six months or less to live.
A research project conducted by Joanne Lynn, MD, SUPPORT co-principal investigator, and colleagues cited in last month’s Hospice Management Advisor,2 underscores this difficulty. In two large studies of prognosis, neither attending physicians nor computerized statistical models were able to predict with more than 50% accuracy a patient’s likelihood of surviving two months even a week before the patient’s actual death.
3. The spread of hospice beyond its natural constituency those who seek it out themselves.
Hospice is still getting patients who welcome the opportunity to get off the high-tech medicine treadmill, but more recent growth has been among patients who prefer to wait until much later before accepting a hospice referral.
"I am reconciled to the fact that our continued growth will be in these short-term patients," says Peter Moberg-Sarver, president and CEO of Hospice of Central New York in Syracuse.
4. Hospice’s "depressing" reputation.
Reports suggest the public has learned a little about hospice but only its association with death, not the philosophy of living fully until you die. For many patients, hospice referral represents giving up and means they are now close to death. Many physicians also have an aversion to mentioning hospice, and so a dance of denial takes place until patients suffer accelerating end-stage crises.
5. Advances in medical treatment.
Many diseases once considered incurable are now responding to experimental new treatments. Protease inhibitors for AIDS is the most dramatic example, but new treatments are also available for illnesses such as pancreatic cancer, once viewed as a death sentence. Other new treatments enhance the patient’s ability to tolerate chemotherapy, bringing new hope and a new willingness to try this harsh anti-cancer therapy.
In some cases, patients may be on the fence, needing support of the kind hospice offers but also wanting to try experimental treatments. The provider’s willingness to accommodate that ambiguity may enhance patients’ receptivity to earlier hospice referrals and an eventual decision to replace curative treatments with a more palliative approach. But this can be financially prohibitive for the hospice, given its all-inclusive, per-diem reimbursement rate. Other hospices are trying to address the gray area with special care or pre-hospice programs, but these are generally not defined as covered benefits, and so reimbursement is likely to be spotty at best.
6. Financial pressures on other providers.
This attitude is difficult to prove, but many hospice managers believe that physicians, home health agencies, and other providers are holding on to hospice-appropriate patients to maximize their own incomes. They refer to hospice only when other sources of reimbursement are exhausted. Carney describes a disturbing new trend for health systems to maximize reimbursement under the Medicare Part A nursing home benefit, even when this is not in the best interests of the patient.
7. The influence of managed care.
Some hospice leaders speculate that the growing presence of managed care in coverage equations or even the specter of future managed care cost controls may be influencing referral decisions.
"We’re blaming the problem on the impending impact of managed care," says Marilyn Hannus, RN, director of Hospice of Cape Cod in Yarmouthport, MA. "Practitioners hold on to patients longer than before and refer them at a much later point" in order to protect their own bottom lines.
References
1. Christakis N, Escarce J. Survival of Medicare patients after enrollment in hospice programs. N Engl J Med 1996; 335:172-178.
2. Lynn, J, et al. Prognoses of seriously ill hospitalized patients on the days before death. New Horiz 1997; 5:56-61.
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