U.S. rules require clearance for long hospice stays
As Marge Bowen examined her last week, Bessie Richburg lay in a hospital bed in the sunny second-floor bedroom of her West Philadelphia rowhouse with her eyes closed.
The muscles of her face rippled and twitched as if preparing for words or an awakening that never came. At 88 and somewhere shy of 70 pounds, Richburg looked wizened and gnomelike among the cheery flowered sheets and blankets.
Bowen, a nurse practitioner with the University of Pennsylvania Health System's Wissahickon Hospice, had come to see whether Richburg still qualified for hospice, which is aimed at people who probably will die within six months. Richburg, who has dementia, has been on hospice since December 2009.
New government rules - enforcement kicked in last month - require hospices to send doctors or nurse practitioners for face-to-face visits with Medicare patients who have been on hospice more than six months to certify that the patients are really sick enough to need the program. The new rules came in response to lengthening hospice stays as services expanded beyond cancer patients to those with slower-moving and less predictable illnesses like heart failure, Alzheimer's, and chronic obstructive pulmonary disease.
Government spending on hospice grew from $2.9 billion in 2000 to $10 billion in 2007, according to a 2009 report from MedPac, the Medicare Payment Advisory Commission that recommended the tougher stance on long stays. During those years, the number of hospice providers rose from 2,300 to 3,200, with most of the growth in for-profits.
MedPac said that hospice is most profitable during long stays, which "may have led to inappropriate utilization of the benefit among some hospices." While the median length of stay has remained steady at about two weeks, the longest stays have gotten longer. The agency estimated that, in about 6 percent of hospices, 40 percent or more of stays exceed 180 days.
The longer stays, MedPac said, blur the distinction between true hospice and long-term care.
Area hospices say the new rules have forced them to hire more doctors and nurse practitioners. Because reimbursements haven't gone up, that's squeezing their budgets. Although few patients actually are dropped from hospice, the new visits also are scaring families that rely on hospice to help them with the arduous work of caring for the dying at home.
"Bessie, I'm going to listen to your heart, OK?" Penn's Bowen said as she bent over the tiny, white-haired woman. She listened to Richburg's lungs and checked for bedsores.
Evangeline Richburg, who has cared for her mother for years, stood by a little nervously. She asked if the family could rent the bed if her mother lost the hospice benefit. The program, which is designed to keep dying patients comfortable and pain-free rather than try to cure their illnesses, gives the family the bed, diapers, medicines, and mattress protectors plus daily 90-minute visits from an aide and less-frequent contact with a nurse and social worker.
"I don't think we're going to take her off of hospice," nurse Sue Foster, who had come with Bowen, said reassuringly.
In the end, Bowen decided that Richburg met criteria to stay on hospice, but she says it's hard to tell how long someone will live. "Prognosis is a guess," she said, "and it's a God question."
The Inquirer contacted two large for-profit hospice companies about the changes. One, Gentiva Health Services, declined to comment. At the other, VITAS Innovative Hospice Care, chief administrative officer Kal Mistry said in a written statement: "It is premature to define the precise financial impact on VITAS' operations, but it is clear the requirement adds to the expenses of complying with the regulations for providing Medicare hospice services."
Among area nonprofits, Wissahickon Hospice estimated the face-to-face visits were taking a day and a half of staff time a week. Crossroads Hospice in Horsham has hired one nurse practitioner because of the new rules. Holy Redeemer Hospice, which has a caseload of 500 patients in Pennsylvania and New Jersey and is doing up to 35 face-to-face visits a week, has hired four nurse practitioners because of the visit requirement. The Visiting Nurse Association of Greater Philadelphia's hospice and Keystone Hospice in Wyndmoor are each hiring two.
Gail Inderwies, Keystone's executive director, said it had been hard to find nurse practitioners willing to go into some of the high-crime neighborhoods her agency serves. She says she may be forced to take some patients to a doctor by ambulance. She worries that the poor will have less access to hospice.
"There are major unintended consequences here," she said.
Judi Lund Person, vice president of compliance and regulatory leadership for the National Hospice and Palliative Care Organization, said her trade group estimated that 30 percent to 40 percent of patients require the face-to-face meeting. She's hearing that many hospices are now doing extra hiring.
"We would have expected a few new positions to get added, but certainly not the volume we anticipate, and I think [Medicare] did not anticipate that at all."
Nurse practitioners make $90,000 to $120,000, said Terre Mirsch, vice president of Holy Redeemer Hospice.
Hospice leaders see some merit in the new requirement. Though nurses were reporting frequently about patients before, the face-to-face visit adds more information and has the potential to identify bad operators in the industry.
"I think it promotes a little higher quality and it will weed out the places that aren't doing well," said Jane Feinman, senior vice president of hospice for VNA's Hospice of Philadelphia.
Hospice officials said patients do sometimes stabilize or even improve enough to lose their eligibility, but quite a few of them deteriorate after they lose their hospice help. "Hospice winds up being a safety net for these patients," said David Casarett, chief medical officer for Wissahickon Hospice.
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