HHS is spreading the word to bolster the use of hospice

Agency clarifies Medicare hospice benefit for reluctant physicians

One of the roadblocks to appropriate hospice admission has always been the six-month terminal illness diagnosis. Physicians complain that making such a prognostication amounts to fortune-telling and that patients can often live longer than six months, even with a certification of terminal illness.

Hospices have responded to reluctant physicians by attempting to explain that certifying someone as terminally ill doesn’t mean they have to die within six months. Rather, it means there is a strong likelihood that the disease will claim a patient’s life but that it’s acceptable for a patient to live more than six months after certification of terminal illness.

With average lengths of service remaining static for the past few years, it is obvious that hospice efforts have fallen on deaf ears. There is renewed hope, however, that the message will finally take root and spread among physicians so that terminally ill patients will be referred to hospice sooner. The reason for that hope is a message that the U.S. Department of Health and Human Services (HHS) is delivering directly to physicians and consumers.

In a letter sent to a variety of physician trade associations, HHS Secretary Thomas A. Scully advised physicians to consider hospice care for their patients sooner and not to misinterpret the terminal illness requirement.

"We are concerned that some individuals who may want hospice care, and could benefit from it, may not be learning about it or may be learning about it too late in the course of their illness," Scully wrote. "Therefore, we are requesting that members of the physician community, as well as other health care professionals, think more about hospice as they care for terminally ill patients."

Scully attempted to assuage physician concerns about making inappropriate hospice referrals. "We recognize that making these determinations is not an exact science and that the impact of hospice services may, initially, improve the patient’s condition," Scully wrote. "Thus, Medicare regulations use the terms expectancy’ and if the terminal illness runs its normal course’ in its definition to indicate that it is entirely possible for hospice services to be needed for more than a six-month period. The Medicare program recognizes that terminal illnesses do not have entirely predictable courses."

To further emphasize its point, the Centers for Medicare and Medicaid Services (CMS) published articles in the Physicians Executive Journal, McKnight’s Long Term Care News, and Caring Magazine. The articles provide information about the benefits of hospice care and reinforce CMS’ message that appropriate end-of-life care must be provided to terminally ill patients.

"This is important, because the regulator of the industry is saying the benefit is unlimited and should be considered for patients," says Jonathan Keyserling, vice president of public policy and communications for the National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA. "[HHS] could have simply issued a dry program memo, but they really stepped up to ensure the message reached those who needed it the most."

A memo extolling the virtues of hospice is nothing new, though. Nancy-Ann Min DeParle, the former administrator of the Health Care Financing Administration (now CMS), wrote a similar letter to the NHPCO in September 2000. In that letter, she said the hospice Medicare benefit was not restricted to six months of coverage; there was no limit for a beneficiary to receive coverage so long as he or she met the eligibility criteria; and a beneficiary could receive hospice care for longer than six months as long as the physician properly recertifies the six-month terminal illness prognosis.

In fact, some of the wording in Scully’s letter seems to have been pulled directly from Min DeParle’s letter. While Keyserling praises Min DeParle’s support of hospice and her effort to clear up misconceptions about the hospice Medicare benefit, the message didn’t reach those who needed it most — physicians. The letter served to reaffirm truths that, while known among hospices, were contested at the time. Federal investigators had looked at a few hospice programs and applied a narrow interpretation of the Medicare Hospice Benefit, which led to the conclusion that hospices were admitting patients who were ineligible for the benefit.

"Min DeParle made it clear that prognosis is not an exact science and that the benefit is unlimited," says Keyserling. "Unfortunately, the letter was directed to hospices."

Keyserling credits the current administrator’s open-door policy for expanding the message beyond hospice and says there is an ongoing dialogue between the HHS administration and hospice leaders regarding the Medicare hospice benefit.

Spreading the word

Keyserling and other industry experts say hospices should use Scully’s letter and the newly published articles to reinforce the message they have been giving physicians for years. In fact, the NHPCO has also notified more than 200 health care organizations of the CMS administrator’s recent clarification via a "Dear Colleague" letter.

"It was a wonderful endorsement of hospice," says Lisa Spoden, PhD, MBA, executive director of the Kentucky Association of Hospices and Palliative Care in Lexington, and vice president of Strategic Health Care in Columbus, OH.

Hospices should give referring physicians copies of the articles and Scully’s letter to ensure the message reaches them. At Hospice of Central Iowa in West Des Moines, administrator William Havekost is using the Scully letter to educate the hospice’s fiscal intermediary, which has disagreed with the eligibility of some of its patients. But Spoden says sharing letters and articles will only go so far and that hospices need to nurture their relationships with physicians to change their referral habits for the better. Hospices can do this by going to greater lengths to identify and meet physician needs and fulfill them.

These needs include:

  • basic hospice information;
  • an easy referral process;
  • frequent updates about patient condition;
  • pain management information;
  • timely responses to orders and requests.

"Most physicians are unsure of how hospice is financed. We hope that by informing physicians how this works that we will help to decrease late referrals," says Sally Aldrich, RN, MSN, director of Methodist Alliance Hospice in Memphis, TN. "What we are trying to do is promote more communication."

Spoden agrees that communication is important. She advises hospices to designate a single person to be responsible for communicating with physicians. The physician liaison should have a health care background and be a member of the hospice’s administration, she says. This is important to encourage physicians to be confident in the information being provided to them, Spoden says.

"It takes a special kind of nurse to do this job," Spoden says. "You need someone who is open to opportunity, a problem-solver."

Methodist Alliance Hospice assigns a marketing person to the task of physician communication. But the position goes far beyond traditional notions of communicating the hospice philosophy. Aldrich says the physician liaison at Methodist Alliance Hospice is responsible for communicating admissions guidelines to physicians and explaining the Medicare hospice benefit.

By educating physicians on proper hospice admission, Methodist Alliance Hospice has been able to add days to its median length of service. Two years ago, the hospice had an LOS of 25 days. Last year its LOS rose to 29 days, says Aldrich. Since then, the median length of service has dropped to 20 days.