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The Good: Connecticut Will Cover Hospice Care for Medicaid Recipients 

Medicaid recipients in Connecticut will soon have access to hospice care.  The new benefit closely resembles the Medicare hospice benefit.  To obtain hospice care, Medicaid clients must be certified as having a life expectancy of six months or less if the illness runs its normal course.  The client must elect the hospice benefit which is palliative (comfort care) in nature, and in so doing forego Medicaid payments for curative treatment of the terminal illness.  Like the Medicare benefit, the Medicaid hospice benefit is elected (chosen).  In other words, it cannot be forced upon individuals who would rather continue traditional care. 

For those who do elect hospice care, the benefit is comprehensive and should assist clients and their families with the dying process.  Covered care includes: medications and durable medical equipment related to the terminal illness; physician, nursing, social work, and home health aide services; physical, occupational; and speech therapy; dietary, spiritual and bereavement counseling; inpatient care and continuous care during periods of medical crisis; and respite care to permit caregivers the opportunity for care giving reprieve.

According to the Connecticut Department of Social Services, the hospice benefit should be available to clients on November 01, 2009.     

The Bad: Reports Raise Concerns Regarding the Provision of Medicare-covered Hospice Care to Beneficiaries Living in Nursing Facilities

Medicare beneficiaries who live in nursing facilities can receive Medicare-covered hospice care if they are certified as terminally ill, elect the hospice benefit, and the facility and hospice have a contract.  Under these circumstances, the hospice assumes professional management of the resident's hospice services and the facility assumes responsibility for the provision of room and board.  Room and board includes:  performance of personal care services, assistance in activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of a resident's room, and supervising and assisting in the use of durable medical equipment and prescribed therapies. 

Hospice care for patients living in nursing homes has caused concern.  This is because some suspect that hospice providers are providing little or no extra care to dying residents than the care already provided by the nursing facility.  Because of this concern, hospice care rendered in skilled nursing facilities has garnered increased scrutiny.  As a preliminary finding, in 2008, the Medicare Payment Advisory Commission found that the Centers for Medicare & Medicaid Services (CMS) "has virtually no information on the hospice care it purchases, in terms of either the specific services provided or the quality of care obtained."  CMS has since begun collecting some information regarding the care it purchases. 

On September 4, 2009, the Office of Inspector General (OIG) issued a damning report finding that 82% of hospice claims for beneficiaries in nursing facilities failed to meet at least one Medicare coverage requirement.  Specifically it found for fiscal year 2006:

• Thirty-three percent of claims did not meet election requirements.  For 4% of claims, there was no election statement.  For another 29% of claims, the election statements did not meet one or more regulations.  Significantly, the most common problem identified was that election statements did not explain that hospice care was palliative rather than curative or that the beneficiaries waived Medicare coverage of certain services related to their terminal illnesses.  For another 9% of claims, the election statements contained misleading language about the beneficiaries' right to revoke the election of hospice care.
   

• Sixty-three percent of claims did not meet plan of care requirements.
   

• For thirty-one percent of claims, hospice provided fewer services then outlined in beneficiaries' plans of care.  Most commonly, the hospices provided services to the beneficiaries but not as frequently as ordered in the plans of care.  In the most extreme cases, there was no documentation in the medical records of any visits for a particular service.
   

• Four percent of claims did not meet certification of terminal illness requirements.  For these claims, the certifications did not specify that the individuals' prognoses were for life expectancies of 6 months or less if the terminal illness ran its normal course; they were not supported by clinical information and other documentation in the medical records; or they were not signed by physicians. 

On September 11, 2009, the OIG issued another report containing information for fiscal year 2006: 

• 31% of Medicare hospice beneficiaries lived in nursing facilities and Medicare paid $2.59 billion for their hospice care.
   

• In nursing facility settings, hospices provided an average of 4.2 visits per week of nursing services, home health aide services, and medical social services combined.
   

  • Home health aide services were provided most often, at an average of 2.2 times per week. 

  • Nursing services averaged 1.7 visits per week. 

  • Medical social services usually occurred on a monthly or bimonthly basis, averaging about .4 visits per week. 

These reports do not reflect well on the hospice industry and thus may bolster concerns regarding the provision of hospice care to Medicare beneficiaries living in nursing homes.  Particularly alarming is the finding that providers are rendering hospice care to Medicare beneficiaries without adequately explaining the consequences of the hospice election - that in electing hospice care beneficiaries forego Medicare payment for curative treatment and are opting for comfort care only.  Also alarming is that the average frequency (4.2 visits per week) of hospice visits to nursing home residents appears quite low. 

To allay these concerns, CMS must increase the frequency of provider certification surveys.  Moreover, the industry must make serious efforts to self-correct.  When providing care to beneficiaries living in nursing facilities, providers must comply with the Medicare regulations regarding coverage.   And even more importantly, providers must provide enough hospice care, and hospice care of high enough quality, to ensure that the dying may die peacefully.  

Future reports must have better outcomes.  If they do not, those concerned with the provision of hospice care to nursing home residents will have justification to discontinue the coverage or make it more difficult to access.   This would be a dreadful result.  All Medicare beneficiaries, regardless of where they live, should have access to hospice care.

The Ugly: Death Panel Scare Could Hurt Access to Hospice Care   

Last summer a group of politicians and talk show hosts hijacked our nation's health care reform debate by seizing upon an amendment in the House of Representatives' health care bill.   The bill permits payments to doctors for the provision of end-of-life counseling every 5 years or sooner if the patient is diagnosed with a terminal illness.  The involved politicians and talk show hosts scared many Americans by alleging this provision meant the Government would create death panels charged with killing the elderly, sick and disabled.  This falsehood was distracting and temporarily derailed the health care debate.  But it also has long term implications for end-of-life care.  The death panel scare could mean the designated payments to physicians for end-of-life care counseling will never see the light of day.  

The Center for Medicare Advocacy urges Congress not to abandon this provision.  Medicare should pay physicians for end-of-life counseling.  Such counseling will encourage more people to engage in advance care planning, and will educate more people about the option to elect the Medicare hospice benefit. 

Conclusion

Hospice care offers comfort to many beneficiaries – and their families – at the end of life.  Americans who die without the support of hospice care often die with needless pain and often die in emergency rooms, without the support of friends or family.  Given this, it seems logical that access to hospice care be maximized as much as possible.  The Center for Medicare Advocacy applauds Connecticut and any other states that initiate a Medicaid hospice benefit.  That said, however, caution must be taken in oversight of providers, and in correcting misrepresentations about hospice care that might undermine the program.  Advocates should not simply be aware of the hospice benefit as an option, but must ensure that it is represented and provided appropriately.

References:

CSA §§ 17b-262-829 to 17b-262-845.

Medicare Payment Advisory Commission, "Report to Congress:  Reforming the Delivery System," June 2008, Chapter 8, p. 224.

OIG, "Medicare Hospice Care for Beneficiaries in Nursing Facilities:  Compliance with Medicare Coverage Requirements," OEI-02-06-00221.

OIB, "Medicare Hospice Care:  Services Provided to Beneficiaries Residing in Nursing Facilities," OEI-02-06-00223.