95% of Inpatient Providers Would Get an F On This Exam

You all think you know hospice. You don’t, and I will tell you why.

Hospice is a bastard child of the Medicare system. It went live in 1983 as a standalone entity during the Reagan administration and remains a disjointed program today. I would characterize its evolution as such: the road to hell is paved with good intentions.

Why is that?

When you go into hospice, your care path goes 180, and usual Medicare rules don’t apply.  The benefit reroute sometimes makes life harder for families and patients.  It’s like handing your keys off into the hospice kingdom–they run the show, and it’s both a blessing and a curse.

You are all familiar with the “likely to survive less than six months” limitation and how it impacts the treatment of the patient and the decision-making we are uncomfortable applying. We make someone hospice and everything changes. No more life-sustaining measures; no heroic technology; no cutting edge pharmaceuticals.

That also includes Medicare Advantage plans (a commercial plan overseeing the full spectrum of Medicare benefits. For newbies, here’s more).  You go hospice, and you get disenrolled* from MA and funneled into the hospice path.  If you think MA should be responsible for patients while in life (and death), it makes no sense to separate the two. MA combines Mcare parts A, B, and D, so why not hospice?  But it is what it is.

Payment is different for hospice, and it’s not customary Medicare fee for service. That explains the reluctance of many hospices to take on the costs of many of the things we might like them to do. That’s the lesson and the reason for the failing grade: providers do not know this. Hospices get one per diem rate for care and given what patients require expenses often do not meet needs.

There are four levels of care (and payment), and we distinguish them by labor and intensity:

95% of hospice service is RHC (routine home care), and it reimburses $191 per day. You can see the other levels and their respective payments. That’s all the hospice provider gets—so if you want to give the patient an expensive antibiotic it comes out of the hospice’s program pool of funds.  A problem. There are some CMS demonstrations going on now that test whether offering simultaneous hospice and treatment benefits improves QOL and outcomes, but answers will take time.  We’ll see.

Anyway, this short briefer is excellent. Have a look, and it will help set you straight on the ins and outs of the benefit.

*Not quite “disenrolled” but a change in how an insurer, a Medicare Advantage provider in this case, defines a “covered” service.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

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