Hospices must pay millions
Hospices must pay millions
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5
By Jeff Raymond
Published: October 15, 2007
Oklahoma hospices must return millions in Medicare funds because their terminally ill patients lived too long.
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The qualifications
To receive hospice care, a patient must agree to forgo curative treatment, and two doctors must certify that the person has no more than six months to live. Patients are certified for hospice upon admission, every 90 days for six months, and then for an unlimited number of 60-day periods thereafter. In 2006, more than 1.2 million Medicare beneficiaries and their families received hospice care.
A hospice's reimbursement is subject to an annual spending cap, which is retroactively calculated based on a federally set amount and the number of patients the hospice served. The cap is not geographically adjusted and is about $20,000 per patient.
Payments from Medicare that exceed the cap must be refunded. Medicare began paying for hospice care in 1983, and Congress in 1998 expanded hospice benefits beyond cancer.
Fighting the cap
Lois Armstrong, president of Oklahoma and Arizona hospice Sojourn Care and a founder of the hospice access alliance, said her family-owned hospice is among those facing potential financial ruin under the cap. Sojourn is based in Tulsa and serves 21 counties within an 80-mile radius of the city.
She said the cap was a result of the Medicare agency reaching out to potential hospice recipients.
"These are the people that are dying of all the things Americans are dying of,” she said. "The cap absolutely penalizes hospices and patients when people take too long to die.”
Sojourn owes about $2 million — almost 20 percent of its reimbursement — for exceeding the cap. "We don't have $2 million. We spent it taking care of patients who were medically eligible,” Armstrong said.
The Medicare agency provided Oklahoma hospice cap statistics but declined to comment further, citing a lawsuit Sojourn filed against it earlier this year.
"Only a very small percentage of hospices exceed the cap,” agency spokeswoman Mary Kahn said in an e-mail.
However, agency officials have argued that many people stay much fewer than 180 days, giving hospices room for longer stays.
David Daucher, a partner in Sojourn and the hospice access alliance, said the "narrow” lawsuit is specific to Sojourn's repayment and is not a legal attack on the cap. The lawsuit is pending.
Armstrong said meticulous standards exist for admission to hospice programs. A dementia patient at Sojourn, for example, must have very limited brain function and have a "comorbid” condition such as an upper urinary tract infection or a pressure ulcer.
"It's based on medical evidence,” she said. "I'll tell you, Alzheimer's patients are mighty unpredictable.”
Before the standards were in place, doctors were reluctant to refer patients with diseases other than cancer to hospice care, she said.
Daucher said the cap results in care-rationing.
One way hospices do this is by limiting the number of patients with diseases other than cancer or those who previously have had hospice care. For Sojourn, this is not an option, Daucher said.
"It really just cuts the heart out of who you are,” he said, adding that patients with diseases other than cancer often are the oldest and most frail. "We have no idea how long they're going to stay. What we know is: Are they eligible?”
Cancer patients make up about a quarter of Sojourn's caseload, he said.
Armstrong, who has 19 years of hospice experience, pointed to a 2007 Duke University study that found hospice care during a patient's last year of life saves $2,309.
"Hospice is the rare situation in which something that improves quality of life reduces cost,” she said.
A changing environment
As hospices admit a greater number of patients who resemble the communities where they live, the average length of stay increases, Daucher explained.
He said 41 percent of Oklahoma hospices owed the Medicare agency $25 million for 2005.
The reimbursement amount has been doubling in recent years.
Although states that have a large number of hospices per capita are hardest hit, the problem isn't limited to southern states.
Instead, he said, it is a growing problem nationally that follows hospice awareness.
Whether there are too many hospices in Oklahoma is the wrong question, he argued.
The real question, he said, is how many of the state's terminally ill residents are admitted to hospice care.
He estimated slightly more than half were and said the number is higher elsewhere — as many as two thirds in Arizona.
"Our view is it's this wonderful benefit that's appropriately growing quickly,” he said.
"It's a long way from being overdeveloped.”
Dr. Gregg Eichman, who oversees medical education for St. Anthony Hospital and is board-certified in hospice and palliative medicine, noted the area's many hospice providers.
"The competition in the market in hospice is just insane, compared to other places,” he said.
Armstrong said family members often tell her they wish they had known about hospice care sooner.
Although hospices may ask CMS for extended repayment terms, the arrangement comes with 12½ percent interest and piles onto hospices whose finances are already in the red.
The hospice access alliance is asking Congress to freeze the cap, stop collections and study a long-term solution.
"We just want hospices to be able to provide good care for eligible patients ... without being asked to refund the money two years later,” Daucher said.
Not all Oklahoma hospices are calling for a cap moratorium. Apart from cancer
Eichman said hospice physicians are comfortable with certifying patients, but other physicians often are not.
However, he said, "If you have someone who is obviously a hospice patient, frankly, they don't have that long to live.”
He said guidelines offered some "leeway” for admission, but doctors didn't want to be accused of bilking the system.
Patients are re-evaluated while on hospice and can be removed, and ailments such as those that affect the heart and lungs often have survival rates that are worse than cancer's.
"The reality is there probably are many more patients out there with end stage non-cancer stuff than with cancer,” Eichman said.
About half of his patients have cancer.
He estimated the average time spent in hospice locally is less than 30 days.
Eichman said guidelines are necessary and will always be a part of federally subsidized medical care.
Nonetheless, he doesn't regret those he has referred to hospice care.
"Very rarely, in retrospect, do I feel like it has been inappropriate,” he said.
"... I think we're still missing a tremendous opportunity with our terminally ill patients.”
Related Topics:
Health and Fitness, Medicine, Social Issues, Cancer, Death and Dying, Health Care Costs, Health Care Issues
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I've been out of the realm for 10 years, and it doesn't look like its improved any.
Why not just give them the power to kill the patient if they live past the 6 month time limit? Medicare would be assured of not spending too much on one person.
Hospice provided much needed care for my Mother when her time came.
This is a good way to put all the providers out of business. Keep it up, Jerks!!!!