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    Top facts primary care physicians need to know about hospice care

    As Medicare spending on hospice care has grown steadily in recent years—reaching $15.1 billion annually—the government has stepped up its regulatory scrutiny of hospice enrollment practices to make sure that only appropriate patients are being admitted.

    Some primary care physicians (PCPs) might wonder when, how and even whether to utilize hospice care for the benefit of their patients who experience advancing illnesses.


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    In January, the federal Centers for Medicare and Medicaid Services (CMS) implemented new payment policies for the Medicare hospice benefit, which included bifurcating the routine, all-inclusive daily rate paid to hospices based on how long the patient is on service. The per-diem payment for routine hospice home care is now higher for the first 60 days of hospice care and lower thereafter. An hourly service intensity add-on (SIA) hourly payment was established for in-person home visits by hospice registered nurses and social workers to hospice patients during the last seven days of their lives, determined retroactively by Medicare Administrative Contractors.[i]

    The former change need not concern referring physicians, says Joan Harrold, MD, MPH FAAHPM FACP, vice president of medical services at Hospice & Community Care in Lancaster, Pennsylvania. Late referrals to hospice for patients who have only a few days to live occur more frequently than referrals that are made “too soon,” before they meet Medicare’s requirements for a documented prognosis of six months or less to live, assuming the disease runs its expected course.


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    But referring physicians might notice that their hospice patients are now getting extra attention at the very end of life, when it is most needed. That’s a good thing, Harrold says.

    “Medicare wants more RN and social work support for patients and families at the end of life—and is paying extra for it. I believe the SIA is a sincere effort on the government’s part to match payment to acuity of care,” she says.

    Other recent regulatory changes include adding more quality measures to the Hospice Quality Reporting Program. Hospices are now mandated to submitdata on National Quality Forum-approved measures. CMS plans to start reporting these data to the public next year on a “Hospice Compare” website. The Medicare Care Choices Program is a five-year pilot to test a concurrent model of care where patients can receive both usual medical treatments and some of the supportive services of hospice care.

    CMS and its “alphabet soup” of contracted regulatory bodies have been stepping up post-payment audits of hospice claims, looking for those that don’t meet Medicare’s clinical criteria for hospice eligibility. Sometimes these audits end up in court through False Claims Act lawsuits and in the press. But that doesn’t mean the patients aren’t very sick, Harrold says.

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    Larry Beresford
    Larry Beresford is a contributing author for Medical Economics.


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