I had not been paying much attention to NHPCO’s flurry of activity during March regarding prognosis vs. diagnosis until I received an email from a well-respected hospice CEO that said, in part:

“Our Medical Director is livid and is adamant that what ‘influences’ the prognosis is very different from what is “related to” the prognosis.  This seems like a fundamental shift from what we have been doing for thirty years – is it possible that everyone (including NHPCO) has been so wrong about this? We think we have financial challenges now – just wait!”

Needless to say, that email caught my attention and I delved further. That CEO has good reason to be worried and to question.

To summarize NHPCO’s position:

  • Hospice providers must reframe how they characterize patients and shift from a single diagnosis to a more comprehensive view that utilizes all diagnoses and conditions that contribute to each patient’s terminal prognosis.
  • In making this shift, providers need to ask the question “Does this diagnosis or condition contribute to or influence the patient’s terminal prognosis?”  If the answer to the question is yes, it becomes the hospice’s responsibility (including financial).

In other words, NHPCO has adopted CMS’ non-regulatory contention from the preamble to the first hospice regulations in 1983 (raise your hand if you read that preamble or any other in your life!) that “it is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients” and their further statement that “unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services will be considered related.”

That preamble ramble had not resurfaced until 2013 when the whole Part D brouhaha (love that word) reared its ugly head.  As I recall at the time, NHPCO was pretty upset with the “virtually all” statement and CMS’ renewed emphasis on this 30-year-old non-regulatory statement as justification for slamming the hospice industry on Part D payments.

I don’t know what changed, but NHPCO gives three reasons for why hospices need to adhere to this cultural shift or “new paradigm” of how hospices should characterize, think about, document and pay for hospice patients:

  1. This is nothing new, the emphasis has always been on prognosis;
  2. If hospices don’t do this it is likely CMS will subject the industry to even more draconian measures; and
  3. It is the right thing to do.

Let’s unpack/discuss each of these reasons.

1. This is nothing new, the emphasis has always been on prognosis

Not really.  Yes, the hospice statute and regulatory text defines hospice eligibility as a patient having a terminal prognosis of 6 months or less.  And yes, CMS can pull its relatedness statements out of a 30-year-old non-regulatory preamble to the original hospice regulations and restate it in 2013 as proof it has always been this way.

But it begs the question – Why wasn’t this an issue for CMS 20 years ago? 10 years ago? Even 5 years ago? Could it be that since hospice is no longer “budget dust” (although when you consider the total budget it still pretty much is), CMS needs to revive the old thinking that maybe made sense in 1983 but hardly makes sense or is even feasible today? CMS needs to protect the Medicare Trust Fund – that is its job. But, unfortunately, like most insurance companies, it wants to pay for as little as possible.

Back to the issue at hand, the hospice industry has pretty much forever focussed on the patient’s terminal diagnosis, his or her terminal illness. Hospices have not done this capriciously nor to narrow their scope of responsibility. Rather, there is very clear regulatory text to support the focus on the patient’s terminal illness/diagnosis. In 418.22(b) regarding the content of the certification of terminal illness, it states:

(b) Content of certification. Certification will be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness. The certification must conform to the following requirements: (1) The certification must specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course. (emphasis added)

It does not say here “terminal illnesses” (i.e., plural) or “terminal illness and co-morbid conditions” or “terminal illnesses and EVERYTHING ELSE THAT COULD POSSIBLY INFLUENCE IT.”

One of NHPCO’s talking points states:

“Over decades of practice in our field, some hospice programs have tended to characterize their responsibility to patients by a single diagnosis, as evidenced on Medicare claim forms.”

I would suggest that rather than “some” hospice programs it is more likely most, if not all, hospice programs have focused on a single or principal hospice diagnosis.  I would further suggest that this single diagnosis focus  has been in response to dealing with LMRP/LCD guidelines, industry teaching, and nobody telling hospices, until now, that they were supposed to focus on prognosis and EVERYTHING, instead of just the patient’s terminal illness.

So no, it has not always been this way.  Neither CMS nor NHPCO can all of a sudden say “Hey, we told you thirty years ago what you were supposed to do and even though we never cared that you didn’t do it before, you had better do it now or….”   Good segue to the next point…

2. If we don’t do this now, it will be worse later

Apparently NHPCO is having/has had a lot of intense conversations with CMS and CMS is pleased with the “proactive” efforts of the hospice industry with regard to the prognosis issue.  I don’t know what they are saying but it sounds as if CMS is threatening worse things if the industry does not fix this issue. Don Schumacher said in his March 5th message: 

“Let me be very clear here, by being more proactive with regards to hospice’s responsibility, we are likely to avoid CMS implementing more draconian changes, changes that might be far more challenging for us to deal with.”

At least there is an implicit acknowledgement that what NHPCO is advocating is “draconian” although less so than what CMS might have in store for hospices.  It sounds like a threat and/or a promise.  I don’t know where to go with that but I do know that threats can be infantilizing and demoralizing.

3. It is the right thing to do

I saved this one for last because it is the big elephant in the room.  First, however, hospices do not need to be “shamed” into doing the right thing. There are very very few hospices that are not out there everyday wanting and trying to do the right thing – with limited resources and intense scrutiny.

But to discuss this further, we may need to harken back to the 90s and question what “it” is.  If “it” is taking care of the whole patient and everything the patient needs to ensure safe, effective and comfortable end of life care then yes, of course, that is the right thing to do.  If “it” is focusing on everything that could possibly “influence” or “contribute” to a patient’s terminal prognosis, in order to broaden the scope of the hospice’s financial responsibility, it is very, very questionable if that is the right thing to do and if it is even feasible.

The elephant in the room here is how are hospices supposed to afford this significant paradigm shift from diagnosis to the all-inclusive prognosis?  NHPCO simply states: “Yes this is likely to increase our responsibilities in a number of ways, but it is the right thing to do.” That may be the understatement of the year with regard to the financial implications of this shift.

When the Medicare Hospice Benefit was conceived in the early 80s, most hospice patients had a primary diagnosis of cancer with a relatively predictable disease trajectory and relatedness determinations were more straightforward.  As hospice has evolved over the years, hospice has broadened access to patients with more complex terminal diagnoses, disease trajectories and needs. What CMS and NHPCO are saying, essentially, is that not only do hospices have to provide patients with everything already included in the Medicare Hospice Benefit, but hospices need to accept full financial responsibility for everything that contributes to or influences (and is therefore related) to the patient’s terminal prognosis and that, with few exceptions, everything is related.  I am not an economist and I don’t know what the per diem for routine home care was back in the 80s in terms of today’s dollars.  I do know that the hospice CEO who sent me that email gets less than $140/day to provide everything for patients cared for by their rural hospice. I also know that most hospices have slim margins, have already been trying to survive with reimbursement cuts and are barely making it. This will likely be an administrative, financial, clinical and compliance nightmare for most hospice programs.

The way it was supposed to work with the Medicare Hospice Benefit’s fixed, per day, per level of care, prospective payment structure was that costs would be spread across a hospice’s entire patient population so that “expensive” patients could be mitigated by “less expensive” patients. That does not work anymore  and hasn’t for a long time.  First, with this new paradigm, all patients are likely to be expensive patients.  Second, it used to be that longer length of stay patients could help spread the costs but in recent years, hospices have been subjected to unprecedented scrutiny for patients with a length of stay close to or longer than 180 days. The message, loud and clear, is hospices better not have long length of stay patients.

Increasingly, hospices are in a no win situation because the Medicare Hospice Benefit was designed in the 1980s and does not work in 2015.  To wit:

  • No other part of the health care continuum is required to provide bereavement services with no reimbursement;
  • No other part of the health care continuum is required to recruit, train and manage enough volunteers to provide at least 5% of patient care hours;
  • No other part of the health care continuum is required to meet professional management responsibilities that include the virtually impossible task of maintaining control of a patient’s plan of care even when the patient is being cared for in an entirely unrelated institution like a hospital or nursing home;
  • No other part of the health care continuum is required to maintain a sufficient number of employees to provide 24 hour care in a patient’s home in the event that maybe a patient will need it rather than contract for additional help when needed; and
  • No other part of the health care continuum is required to pay for everything possibly related to a patient’s prognosis out of a meager per diem payment.

I am not advocating throwing the baby out with the bath water. Rather, doesn’t it seem like energy and resources would be better spent advocating for a revised Medicare Hospice Benefit that makes sense for the financial and clinical realities of 2015? Evidence suggests that mandated hospice payment reform is likely to increase provider burdens, and not do much or anything to address the aspects of the Medicare Hospice Benefit that make the provision of hospice care inordinately and unnecessarily complicated and impractical.

Is this focus on an all-inclusive prognosis another (or final) nail in the hospice coffin for many smaller hospice programs?  Is the hospice industry — as we have known and loved it — on track go the way of the nursing home and funeral industries:  consisting predominantly of large, for-profit chains because they are the only ones that can afford to exist?

Anyone out there?

Posted by Heather P. Wilson, Ph.D., CHC – CEO of Weatherbee Resources, Inc.