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.

More CMS news: MACRA/MIPS is the problem, individual health freedom is the answer

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.

More business news: Post-acute care networks grow amid concerns from independent doctors

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.

Next: PCPs in a unique position

A terminal prognosis is difficult

“First of all, an accurate terminal prognosis is notoriously difficult to determine, unless the patient is imminently dying,” she says. Doctors might see a patient who’s steadily getting worse yet still fails to meet Medicare criteria. But that’s where the primary care physician’s involvement can be helpful, sharing with the hospice the patient’s history and medical issues related or unrelated to the terminal prognosis.

“The primary care physician is in a unique position to see a patient’s decline over months,” she says.

Blog: Physicians shouldn't fear dealth talk with patients

“The truth is, even today, a lot of folks who could benefit from hospice care never get it—or if they do, it’s only with a few days left before death,” notes Joe Rotella, MD, MBA, chief medical officer at the American Academy of Hospice and Palliative Medicine. “So in 2016, we continue to have an access problem. If you can receive hospice care for more than just a few days, it can really make a difference,” he says. “One message I would have for front-line doctors is this: don’t hesitate to call hospice and ask for a consultation if you have any doubt. Think of those patients who continue to return to the hospital despite your best efforts, and have increasing symptoms.”

“If the PCP disagrees with the hospice’s determination that the patient is not eligible, they should collaborate with the hospice and provide more information. When talking to patients and families, the physician can acknowledge that Medicare has well-defined eligibility criteria, which may preclude their admission at this time,” he adds.

The family physician’s role

Family physicians may not realize that they have the option to remain involved as the patient’s attending physician following a hospice referral, Harrold says, as it’s the patient’s choice.

Some doctors prefer to relinquish the responsibility of attending to the hospice medical director. There is also an option of co-management, where the PCP remains involved alongside the hospice physician.

Opinion: Primary care must be the mental health medical home

“There is some work involved with being a hospice patient’s attending physician, such as receiving updates, requests for medical orders and paperwork to sign,” she says. Physicians who want to go that route should be available to respond to such requests.

“I usually do not relinquish that responsibility,” says Robert L. Wergin, MD, FAAFP, a family physician in Milford, Nebraska, and board chair of the American Academy of Family Physicians. “That’s my recommendation to other family physicians: remain as attending after you refer your patient to hospice. Keep those lines of communication open. With the new Medicare regulations, it’s even more important.”

Next: Recommendations

“I tell my patients: ‘I’m not going to abandon you, even after you enter hospice.’ I see them in the office when they’re able, and communicate with the hospice team when they’re not. I also make home visits—as do many family physicians,” Wergin says. That makes a big difference to patients, he says. He adds that conversations about end-of-life choices typically start in his office, where he explains that there are limited options for further aggressive treatment and the family reports that symptoms are mounting.

Wergin also recommends that primary care physicians choose one or two reputable hospices in the community and develop good working relationships and lines of communication with them.

“I steer away from hospice companies that are more aggressive in their marketing—where it seems like they are hammers that see every patient as a nail.”

Wergin practices in a region with a sizeable Mennonite population. “I had a patient who was a Mennonite lay minister. He did not receive hospice care because his family was coping well, and they didn’t need a nurse to explain about death and dying,” he recalls. “I was in the room with the dying patient, and his son got up, walked over to me and put his hand on my arm. ‘My father loves you,’ he said. ‘He’s ready for what’s to come. But we’re worried about you. You’re hanging onto hope.’ He gave me permission to make the transition that the family had already made.”

[i] Medicare Program; FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Federal Register, August 6, 2015. See: https://www.federalregister.gov/articles/2015/08/06/2015-19033/medicare-program-fy-2016-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting.