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
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
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:
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.
of claims did not meet plan of care requirements.
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
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
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
Home health aide
services were provided most often, at an average of 2.2
times per week.
averaged 1.7 visits per week.
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
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
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 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
17b-262-829 to 17b-262-845.
Payment Advisory Commission, "Report to Congress: Reforming the
Delivery System," June 2008, Chapter 8, p. 224.
"Medicare Hospice Care for Beneficiaries in Nursing Facilities:
Compliance with Medicare Coverage Requirements," OEI-02-06-00221.
"Medicare Hospice Care: Services Provided to Beneficiaries Residing
in Nursing Facilities," OEI-02-06-00223.