Call Summary
Medicare Network Conference Call
Emerging Issues with the Medicare Hospice Benefit
July 16, 2003

I.  Introduction

The topic of this call was the Medicare hospice benefit and emerging issues for Medicare beneficiaries and for SHIP counselors. Our guest speakers were Naomi Naierman, President and CEO of the American Hospice Foundation, and Terry Berthelot, Staff Attorney, Center for Medicare Advocacy. Ms. Berthelot was the creator and manager of a hospice program in Mississippi prior to attending law school.

II. When is hospice care an appropriate option? What is the role of SHIP counselors in discussing hospice?

Ms. Berthelot directed attention to CMS Program Memorandum AB-03-040, “Provider Education Article: ‘Hospice Care Enhances Dignity and Peace As Life Nears Its End’ ” (March 28, 2003), available at http://www.cms.hhs.gov/manuals/pm_trans/AB03040.pdf. Medicare carriers and fiscal intermediaries were directed to distribute the text of the memorandum to all Medicare certified health care providers no later than mid-April, 2003. 

The memorandum states:

[p]hysicians and other health care practitioners can be encouraged that the Medicare program includes a hospice benefit that provides coverage for a variety of services and products designed for those with terminal diagnoses. When properly certified and appropriately managed, hospice care is a supportive and valuable covered treatment option. . . .  Hospice is not about death, but rather about the quality of life as it nears its end, for all concerned the patient, family and friends, and for the health professional community.

Ms. Berthelot also cited the National Hospice and Palliative Care Organization, a hospice provider organization, which believes that people have a right to die with dignity and that loved ones should get the support in enabling this to happen. See the organization’s statement about hospice on its Web site at http://www.nhpco.org/i4a/pages/index.cfm?pageid=3281.
Hospice is an underutilized benefit. In 2000, about 23 percent of terminally ill Medicare beneficiaries received hospice care. Of those, 30 percent received hospice for less than one week[1] .

Eligibility for the Medicare hospice benefit is based on the physician’s certification that a patient is likely to die within six months if an illness runs its normal course. In order to be allowed to elect the hospice benefit, both the patient’s treating physician and the medical director of the hospice must certify that in their clinical judgment, the patient’s life expectancy is no more than six months if the patient’s disease runs its natural course. The patient can have a combination of illnesses and conditions that cause death to be near—the physicians’ certification does not need to be based on the progression of a single terminal disease such as cancer. The CMS Program Memorandum quoted above explicitly states: “CMS recognizes that making medical prognostication of life expectancy is not always an exact science. Thus, physicians need not be concerned. There is no risk to a physician about certifying an individual for hospice care that he or she believes to be terminally ill.” The Medicare statutory requirement on terminal illness is broad. The statute requires only that “[a]n individual is considered to be ‘terminally ill’ if the individual has a medical prognosis that the individual’s life expectancy is 6 months or less.” Social Security Act § 1861 (dd)(3)(A); 42 USC § 1395x (dd)[2]. See also 42 C.F.R. § 418.3.

Sometimes hospices develop their own internal objective clinical criteria for admission. You can ask hospices if they have such criteria, and, if so, what they are. However, the statutory definition of “terminal illness” is subjective, in recognition that no one knows whether someone will in fact die in six months. SHIPs should remember that while admission tools are helpful, the statute is broad, and with a treating doctor and hospice director’s certification, patients who don’t seem to fall neatly within criteria listed on an admission tool may still qualify. The CMS memorandum notes that “[t]he hospice setting also is appropriate for patients who suffer from terminal illnesses such as lung disease or end-stage heart ailments, cancer, Alzheimer’s disease and terminally ill AIDS patients.”

If the beneficiary lives longer, Medicare hospice benefits do not terminate. A person remains entitled to the Medicare hospice benefit as long as either the treating physician or the hospice medical director continues to certify that death is anticipated within six months.

By statute, the beneficiary must affirmatively elect to receive palliative and not curative care. The beneficiary makes the election by signing a hospice election form provided by the hospice. See Social Security Act § 1861(dd); 42 USC § 1395x(dd).
 
Nursing home residents are often in a condition that will soon result in death. Does general geriatric deterioration qualify someone for hospice? Ms. Berthelot indicated that SHIP counselors should encourage documentation of the deterioration in residents' nursing home medical records. The physician would still need to certify that a combination of particular ailments is causing death to be imminent.  Medical documentation to that effect is clearer than physician assertions that the person was deteriorating as a result of aging.

IV. Differences between Medicare hospice and Medicare home care benefits

With the Medicare hospice benefit,

1. Patients do not need to receive a skilled service (although hospice nurses often provide a lot of skilled care).
2. There is no requirement that nursing and home health aide care be provided only on a part-time or intermittent basis.
3. There is no homebound requirement.
4. There must be periodic physician certification of terminal illness.
5. Hospice involves an interdisciplinary team approach―typically a physician, a nurse, a social worker, and a chaplain.
6. Palliative medications for symptom control are paid on a per diem basis. Durable medical equipment (DME) is also paid under the hospice benefit, and the usual limitations on DME do not apply as long as the DME is part of the hospice plan of care.

V. Hospice reimbursement and quality of care

Hospices are reimbursed under Medicare on a per diem basis. There are five levels of hospice payments under Medicare:

1. Routine home care- to cover the usual costs of nursing and home health aide services, under a hospice plan of care.
   
2. Continuous home care- used when more intensive and time-consuming interventions are needed during a crisis period, such as when pain management requires time-consuming nursing interventions.
   
3. Respite care- when the patient may be cared for at home or in an inpatient setting while the informal family caregivers take a brief break, usually for a maximum of five days at a time.  Respite care is based on the needs of the family for respite rather than on the individual’s condition.
   
4. Inpatient hospital or skilled nursing facility care- used when inpatient interventions are needed to control pain symptoms that cannot be adequately managed at home. 
   
5. Bereavement care- for the surviving family and loved ones, for up to one year.  While bereavement care is a mandatory hospice benefit, Medicare does not reimburse hospices for providing this service.

There are no limitations on the number of inpatient days covered under the Medicare hospice benefit. Inpatient care to control symptoms is covered as long as it is appropriate. Hospices receive a higher per diem rate of reimbursement for inpatient care. All hospices must have arrangements for inpatient care and must be reachable on a 24-hour basis to meet the needs of dying patients. 

If a hospice patient gets sick with a condition unrelated to the terminal illness, curative treatment must be made available and, if desired, would be covered by regular Medicare benefits. For example, should a hospice patient fall and fracture her wrist, if the fracture is related to the terminal illness, treatment would be a part of the hospice plan of care. If the fracture is unrelated to the terminal illness, all appropriate care should be given to the patient, if desired, and covered by the regular Medicare Part A and Part B benefits. However, in many instances, the patient and the hospice team may decide to leave an illness, such as pneumonia, untreated, opting only for comfort care.

Sometimes, a hospice may decide to keep a patient in the hospital after she no longer needs inpatient care to control symptoms, rather than moving her home, in order to keep the patient comfortable. In this case, the hospice must bill Medicare at the routine home care rate rather than the higher inpatient rate, even though the patient remains in the hospital to maintain her comfort.

Hospice patients can always opt out and go back to the regular Medicare benefit if they are dissatisfied with the care they receive through the hospice. Similarly, a hospitalized Medicare beneficiary can elect the hospice benefit if the eligibility requirements are met.

SHIPs should emphasize to patients and families that while someone is in a hospice, all care must be through arrangements with the hospice. Problems arise when the family or a patient panics and calls 911, rather than calling the hospice to order an ambulance or to go to the hospital.

Ms. Naierman said that hospices must manage the per diem reimbursement to carry out the hospice patient’s plan of care. The hospice plan of care is developed by the hospice team with the participation of the patient and family to meet the patient’s and caregivers’ needs. Hospice is intended to be a home-based benefit, and usually, the plan of care can be satisfactorily implemented through care at home. Some smaller hospices find it hard to spread resources since they do not have the benefits of economy of scale; their services may be sparser, especially in rural areas, where staff travel time and distance is a consideration.

VI. Strategies to work with providers

If family or a SHIP counselor believes that a patient’s hospice services are inadequate, they should advocate for more visits or services. The patient’s physicians can be helpful in advising and advocating for an appropriate level of care. In disputes about whether inpatient care is appropriate for a person in hospice, the family physician, hospice director, and family or SHIP counselor may facilitate a negotiation. If not satisfied with the outcome, a patient can opt out of hospice or transfer to another hospice. However, switching hospices is disruptive, and if possible, it is better to work out arrangements with the current hospice. The aging network can also provide benefits that supplement hospice care, like meals on wheels, and some hospice participants may be eligible for additional care through Medicaid home and community-based care waivers.

VII. Facility-based hospice care

The Medicare hospice benefit may be used by nursing home residents. However, Medicare beneficiaries may not use both the regular Medicare skilled nursing facility benefit and the Medicare hospice benefit simultaneously. The reason for this is that the hospice patient has opted out of regular Medicare by electing the Medicare hospice benefit. The Medicare hospice benefit does not generally cover room and board in a nursing home, except for brief periods of inpatient symptom management or respite care.  The Medicare hospice patient who resides in a nursing home will need to find an alternative reimbursement source for the nursing home bill. Call participants noted that patients or family members may not understand their responsibility for room and board payments when they choose facility-based care.

VIII. SHIPs’ role in informing people about hospice options

Participants shared their tips about discussing hospice:

1. Listen for cues from the individual or family that they are thinking about life coming to a close. 
2. Educate. Don’t preach. Hospice is a choice.
3. SHIPs have an important role. People who are dying are very vulnerable and need assistance and advocacy. Families are often confused and overwhelmed at this time and can use help such as listening to their concerns and offering compassionate assistance.  Sometimes, the SHIP counselor is the helper who is the trusted and respected clear-minded, informed advocate who does not have conflicting incentives. The patient and family must make the decisions, but SHIPs can help them through the discussion.
4. SHIPs can promote timely discussion of hospice by listing hospice as a benefit to ask SHIPs about on general brochures, advertising that they can help with advanced directives, and including information from end-of-life coalitions in other mailings. 
5. Get to know local hospice providers.  Explore whether they will team up to educate people about hospice before death is imminent.  Ms. Naierman observes that a closer relationship with local hospices can help facilitate access to hospice at the time of need and reduce the potential for crises.

Jeanette Koijane, Sage Plus, Hawaii’s SHIP Program, reported on the Hawaii coalition, Kokua Mau, in which the Hawaii SHIP is an active participant.  The Hawaii SHIP has developed tips about how and when to be involved in discussions about end-of-life care. Three cues to listen and watch for are:

1. Has the person lost a lot of weight without trying to do so?
2. Has the person made two or more emergency room visits in the last six months? 
3. Has the person been diagnosed with a serious illness? 
4. Comments like “the doctor says I won’t live to see Christmas” or “my mother has given up and won’t go for treatment” can also open a discussion.

SHIPs also can help educate doctors about hospice by giving them brochures and letting them know of people who had good hospice experiences.  For more suggestions from the Hawaii SHIP on a SHIP response to end-of-life concerns, please click here or contact Sage Plus, Hawaii’s SHIP Program at 1-888-875-9229.

IX. Conference Call Background Materials

For background information on this call, please see an issue brief published by the Center for Medicare Education, The Medicare Hospice Benefit, Vol. 2, Number 9, (2001), authored by the National Hospice and Palliative Care Organization, by clicking here or go to http://www.medicareed.org/content/CMEPubDocs/V2N9.pdf or visit the Center for Medicare Education Web site at http://medicareed.org/.  

The Center for Medicare Advocacy Web site contains helpful and informative material about the Medicare hospice benefit at http://www.medicareadvocacy.org/hospice_coverage.htm. 

The American Hospice Foundation Web site, www.americanhospice.org  has useful resources, including The Medicare Hospice Benefit, http://www.americanhospice.org/griefzone/articles/medicare.htm; What to Expect and Demand From a Good Hospice,  http://www.americanhospice.org/griefzone/articles/medicare.htm; and Debunking Hospice Myths, http://www.americanhospice.org/griefzone/articles/medicare.htm.  

Hawaii's SHIP Program, Sage Plus, has been involved with an innovative coalition, called Kokua Mau, which brings together many Hawaiian partners to integrate end- of-life care into the aging network.  Please visit the Kokua Mau Web site at www.kokuamau.org for more information.

X. Announcements

Upcoming Medicare Network Conference Calls:

1. A discussion for SHIPs in the states with Medicare PPO demonstration plans will be held on July 30, 2003 at 3 P.M. EDT. Please contact Astrid, aschmidt@healthassistancepartnership.org for additional information.
2. On August 4, 2003, SHIPs are invited to participate in a call at 3 P.M. EDT to discuss the question of whether the nation’s consumer health assistance programs should form an association. Please contact Hilary, hdalin@healthassistancepartnership.org, for additional information.
3. The next regularly scheduled Medicare network conference call will be on September 17, 2003 at 4 P.M. EDT. (Please note the time change.) The topic is Web-based medical and legal research tools for SHIPs. This call will be facilitated with a Web-based resource. More information and a special call-in number will be sent out about this call at the end of August.

Up-to-date information about Congressional work on the Medicare prescription drug bill is available on the Families USA Web site homepage, www.familiesusa.org;  on the Kaiser Family Foundation Web site, at www.kkf.org; and at www.shiptalk.org.

Please contact Hilary hdalin@healthassistancepartnership.org with your questions, comments, suggestions, and ideas.