Hospice is comprehensive care for the dying.  The focus of hospice care is comfort, and thus having hospice care can help ensure a peaceful rather than a painful death.    Hospice is covered by Medicare Part A if the beneficiary has a life expectancy of six months or less.  If the terminally ill beneficiary elects the hospice benefit, he waives curative treatment for his terminal illness, but can continue to receive curative treatment for other illnesses.

Hospice was originally envisioned to be a non-institutional benefit.  That is, it was expected that beneficiaries who elected the benefit would receive hospice care within their homes.  However, it is possible to receive Medicare covered hospice care while residing in a nursing home.  And since one out of every three people admitted to a nursing home is expected to die within one year, one would expect that a significant amount of beneficiaries living in nursing homes would be receiving hospice care.   Yet currently, fewer than 15% of nursing home residents receive hospice care.

Contract for Hospice Care:

Mrs. Haviland recently fell and broke her hip.   Consequently, she was hospitalized for three days and then entered a nursing home to participate in physical therapy five days a week.  While she was receiving the physical therapy, Mrs. Haviland’s physician diagnosed her with terminal liver cancer and certified that she had a life expectancy of six months or less.   Technically, Mrs. Haviland qualifies for Medicare hospice coverage.  Realistically, however, there are several hurdles which may make it impossible for her to access hospice care.

The first hurdle is a billing quagmire.  In order to receive Medicare covered hospice care, Mrs. Haviland must reside in a nursing home that has a contract with a hospice agency for the provision of hospice care.  At this time, there is no legal requirement that nursing homes contract with hospice providers.  So even though Mrs. Haviland is dying of liver cancer, if her nursing home does not have a contract with a hospice agency for the provision of hospice care, she will not be able to receive Medicare covered hospice care.

Currently there are many reasons why Mrs. Haviland’s nursing home may be reluctant to contract with a hospice provider for hospice care.  To begin with, the administrators of the nursing home may believe that the staff at the nursing home has the needed expertise to provide end-of life care.  In other words, they may view hospice care as a duplicative service.  Secondly nursing homes are heavily regulated.  The administrators of the nursing home may believe that the hospice philosophy of care, that is, a focus on caring rather than cure, violates nursing home regulations.  Consequently, the nursing home administrators may choose not to contract with a hospice agency for the provision of hospice care.

Room and Board:

There is another significant barrier to receiving hospice care while residing in a nursing home.  This is the fact that the Medicare hospice benefit does not pay for room and board.   For instance, if Mr. Aubois is receiving daily skilled nursing care in the nursing home for his terminal heart condition, regular Medicare Part A pays for both his medical care and his room and board.  However, if he were to elect the Medicare hospice benefit, Medicare would pay for hospice care, but not for his room and board.

This is significant because room and board in a nursing home can cost over $8,000 per month.  So, unless Mr. Aubois has alternative insurance, such as Medicaid, that would pay for his room and board, if he elects the Medicare hospice benefit, Mr. Aubois will also be electing an $8,000 monthly bill for room and board.

On the other hand, Mrs. Haviland qualifies for both Medicare covered hospice care and Medicare covered room and board.  This is due to the fact that she has two diagnoses:  the broken hip which qualifies her for Medicare skilled nursing facility coverage, and terminal liver cancer which qualifies her for hospice coverage.  As long as Mrs. Haviland continues to receive physical therapy five days per week, Medicare will cover her physical therapy, her hospice care, and her room and board.  Unfortunately, once her physical therapy ends, although she will continue to be eligible for Medicare covered hospice care, Medicare will no longer cover Mrs. Haviland’s room and board.

General Inpatient Hospice Care or Respite Care:

Alternatively, room and board in a nursing home can be covered under the Medicare hospice benefit if the beneficiary requires hospice general inpatient care or hospice respite care.  For example, if Mrs. Bailey was receiving hospice care at home, but her care became unmanageable in the home, she would qualify for the hospice general inpatient benefit.  That is, she would be transferred to an inpatient unit (either in a hospital or in a nursing home) where her care could be managed.  While Mrs. Bailey was receiving her hospice care in the inpatient unit, Medicare would pay for her room and board.

Hospice respite care differs from general inpatient hospice care in that coverage is triggered not by the beneficiary’s medical need, but by the needs of the beneficiary’s family.  Mr. Cassidy, for instance, was receiving Medicare covered hospice care in his home.  His primary caregiver was his wife, Mrs. Cassidy.  Due to the demands of caring for a dying person, Mrs. Cassidy has not been sleeping well.  Of course, it is not healthy for a person to go without sleep.  Under the Medicare hospice benefit (so that she can catch up on her sleep), Mrs. Cassidy can be spelled from the demands of caring for her terminally ill husband.   This spell is called respite care.  During respite care, Mr. Cassidy will be treated in an inpatient unit (either a hospital or a nursing home), so that Mrs. Cassidy can catch up on her sleep.   During respite care, Medicare will pay for both Mr. Cassidy’s hospice care and for his room and board.

What Needs to Change:

Ideally, Medicare should cover room and board for beneficiaries who reside in nursing homes and have elected the hospice benefit.  This change requires Congressional action as it can only happen if there is a change in the Medicare statute.  In the mean time, as a condition of participation in the Medicare program, the Centers for Medicare and Medicaid Services (CMS ) should require that nursing homes establish contracts with hospice providers for the provision of hospice care.  Or, at the very least, as a condition of participation, CMS should require that nursing homes inform potential residents about the Medicare hospice benefit and whether or not the nursing home has a contract with a hospice program.

CMS should also encourage nursing homes to contract with hospice agencies for the provision of hospice care.  To this end, through education and explicit statements of policy, CMS should ensure:  that nursing home providers understand that hospice care is a distinct benefit from nursing home care; that hospice care will enhance the quality of care provided within the nursing home; and that the palliative focus of hospice care does not violate nursing home regulations.

Conclusion:

Terminally ill Medicare beneficiaries can receive Medicare covered hospice care while they reside in a nursing home.  However, there are several hurdles to accessing this care.  These include the requirement that the nursing home have a contract with a hospice provider for the provision of hospice care and the fact that the Medicare hospice benefit does not generally include financial coverage for room and board.  Given the importance of ensuring that Medicare beneficiaries do not die in pain, Congress and CMS should change the law and policy such that those living in nursing homes can more easily access hospice care.