The Hospice e-News

What the Media Said about End-of-Life Care This Week

Week of April 17, 2006

…a service of Florida Hospices and Palliative Care

MEDPAC MAY RECOMMEND HOSPICE PAYMENT CHANGES

MedPAC is considering recommending changes to the hospice payment system, according to an article in Eli’s Home Care Week, in its June report to Congress. The article reports that there will likely be no adjustments based on case mix, but that payments would probably be redistributed from the middle days of a hospice stay to the beginning and end.

One MedPAC staffer says that a RAND analysis of one for-profit chain’s data didn’t “make a compelling case that case mix adjusters based on patient characteristics would improve the accuracy of the payment system.” Others say that adding a case mix adjuster wouldn’t be a good idea because of the “significant increase in the amount of data that hospices would be required to collect and manage,” and also because a case mix adjuster “could lead hospices to cherry pick the most lucrative patients.”

RAND’s analysis showed that more intensive care was delivered in the first and last days of a patient’s hospice stay, particularly in the last three days. But consultant Beth Carpenter says that changing payments to reflect that may harm hospices that are accepting many non-cancer-diagnosis patients. “This movement of the hospice population to other types of diagnoses results in longer lengths of stay and a whole lot of days in between start of care and the final days. As lengths of stay move higher, a lower rate for the intervening days could be potentially damaging to agencies that manage the care of longer stay patients,” she says.

John Mahoney, principal of New Jersey’s Summit Business Group, says, “The beauty of the current system is its simplicity. I’d be reluctant to corrupt that simplicity just for some marginal tweaking.” Carpenter says, “Drawing conclusions from the report of one stand-alone for-profit chain is interesting for the sake of discussion, but not appropriate for making decisions on funding schemes. Profitability is influenced by census size, length of stay, diagnosis mix, intensity of services, level of care decisions, etc.,” she says.

If MedPAC does recommend changes to Congress, the following are the “crucial data” that the recommendations will be based on, the article says.

* Medicare will spend $9.8 billion on hospice this fiscal year and payments are expected to increase 9% per year through 2015.

* Medicare pays for 88% of all hospice care.

* Routine hospice days accounted for 93% of billed hospice services in 2003.

* Twenty-two percent of fee-for-service Medicare beneficiaries elected hospice in 2000, compared to 31% in 2004.

* Between 2000 and 2004, the number of hospice days billed doubled, the number of hospice users grew by half and payments increased 130%.

* Between 2000 and 2004, the median length of stay remained at about two weeks, but the mean length of stay increased from 51 days to 67.

* In 2003, fewer than half of all hospice patients were diagnosed with cancer. Non-cancer patients have longer average lengths of stay.

* In 2001, 31% of hospices were free-standing for-profits; in 2006, 47% are.

* Staff at MedPAC found research showing hospice profit margins: the GAO calculated them at 10%, NHPCO at 11-19% and the Journal of Palliative Medicine at 2% for non-profits and 18% for for-profits. (Eli’s Home Care Week, 3/20)

PALLIATIVE CARE AT A “TIPPING POINT”

The number of palliative care programs in US hospitals increased 63% between 2000 and 2003, from 632 to 1,027. Dr. Sean Morrison, primary author of a study reported in Family Practice News, says that the study “demonstrates the increasing recognition by hospitals in the United States and those providing primary care for patients with advanced illness of the need for palliative care services.”

Morrison, who is vice chair of research in the department of geriatrics at Mt. Sinai Medical Center, says that palliative care is “becoming part of what should be routine medical care. We have seen growth from a fraction of hospitals having hospital-based palliative care programs to where now 1 in 4 hospitals have a program. I'm not going to be satisfied until 100% of hospitals have [a palliative care program], but for patients and families, I think we're at the point where they do have access to this type of care. I think we are at a tipping point.”

The researchers found that palliative care programs are more prevalent in hospitals in the Northeast, Pacific and Mountain areas of the country than in other geographic areas. The likelihood that a hospital has a palliative care program directly correlates with the number of hospital beds and acute care beds. VA hospitals and not-for-profit hospitals are more likely than others to have programs. Other factors which correlate positively with the presence of palliative care programs are membership in the American Association of Medical Colleges Council of Teaching Hospitals and being a cancer hospital approved by the American College of Surgeons.

Dr. Daniel B. Hinshaw, medical director of the palliative care consult team at the Ann Arbor VA Medical Center, says that the increase in the number of palliative care programs “gives us an opportunity to keep that message out there that this [component of care] is not just a matter of fighting disease. It’s really about caring for the whole person who might have a bad disease.”

Dr. Geoffrey P. Dunn, co-chair of the American College of Surgeons’ Palliative Care Task Force, says that the “current funding landscape” for hospital-based palliative care programs is “tenuous,” in spite of several demonstration projects proving their cost-effectiveness. Dunn is also concerned about finding enough physicians to staff the programs, particularly with the expected approval of hospice and palliative medicine as a subspecialty by the American Board of Medical Specialties.

A financial calculator that helps estimate the cost of a palliative care program and possible savings for a hospital is online at www.capc.org. Look for the “CAPC Impact Calculator” under the “Tools” section. (Family Practice News, 2006;36(5):1)

HOSPICE AND PALLIATIVE MEDICINE SUBSPECIALTY ENDORSED

An article in Family Practice News says, “The pending designation of hospice and palliative medicine as a subspecialty by the American Board of Medical Specialties is expected to hasten the spread of palliative medicine into routine medical care, and may boost the number of physicians who train and seek certification in this field.”

In September, 2005, the American Board of Internal Medicine (ABIM) applied to the American Board of Medical Specialties (ABMS) to “make hospice and palliative medicine a subspecialty of internal medicine.” Co-sponsors with ABIM are the American Board of Family Medicine, the American Board of Anesthesiology, the American Board of Psychiatry and Neurology, the American Board of Surgery and the American Board of Physical Medicine and Rehabilitation.

The ABMS will probably decide favorably in September, 2006, with the first certification examinations to follow in 2008. (Family Practice News, 2006;36(6):78)

PUBLIC POLICY NOTES

* Oklahoma’s living will law “restricts a person’s right to refuse artificially administered water and food” and Attorney General Drew Edmondson says the law is unconstitutional. An article in The Daily Oklahoman reports that Edmondson’s opinion, which is advisory and nonbinding, “is in line with a 1990 US Supreme Court decision that a competent person has a constitutionally protected right to refuse life-saving hydration and nutrition.” Current law requires that a person have a terminal disease or be persistently unconscious for previous directives to withhold food and water to be honored. As an example, the article says, a person may not, in advance of developing Alzheimer’s disease, specify that he or she does not want artificial nutrition and hydration, because Alzheimer’s is not necessarily terminal and an Alzheimer’s patient is not necessarily persistently unconscious. (The Daily Oklahoman, 4/8)

* The Orlando Sentinel says that Governor Jeb Bush (R) has been “unable to reopen the legislative debate over Terri Schiavo” and “is giving up on his effort to change Florida law to allow patients to reject or withdraw a feeding tube only if they put that wish in writing.” The article says that Bush was unable to find legislative sponsors for his recommendations. (The Orlando Sentinel, 4/13)

* The Louisiana House has unanimously supported a resolution “calling on the state Department of Health and Hospitals and the Governor's Office on Homeland Security and Emergency Preparedness to come up with better ways to care for hospice patients forced to evacuate during hurricanes or other emergencies.” Representative Sydnie Mae Durand (D) says that hospice patients’ needs should be considered when the state sets up “special needs” shelters during emergencies. (The Times-Picayune, 4/9)

The Minnesota Legislature is considering the Minnesota Starvation and Dehydration of Persons with Disabilities Prevention Act. A viewpoint in the Grand Forks Herald says, “Not only does the proposed law presume all Minnesotans will want to be kept alive indefinitely, but it also could enable a minority of relatives to override your own advance directive in cases where the directive does not speak to every last detail of your diagnosis, prognosis and treatment. … This law would guarantee unnecessary government intrusion in most, if not all, cases in which families seek to withdraw life-sustaining treatment — even if the patient’s wishes were clear and known to the family. This is clearly not what Minnesotans want for their loved ones and themselves.” (Grand Forks Herald, 4/9)

OTHER NOTES

* Resources for the Community Engagement Campaign for the TV series, “A Lion in the House,” are available at www.itvs.org/outreach/lioninthehouse/resources.html. All campaign materials are provided at no cost to groups working with the campaign. “A Lion in the House,” which will air on PBS stations in June, tells the stories of five young cancer patients over a six-year period. (A Lion in the House Website)

* An article in Atlanta Hospital News featured Abbey Hospice as an example of the ways rural hospices meet challenges never dreamed of by urban hospices. In some cases, nursing assistants fill buckets of water at their homes to use in bathing patients who have no running water. Patients have less privacy, because neighbors recognize the hospice nurse’s car. Friends may stop the hospice staff at the store or at church to ask how a patient is. But less privacy can also be a help, as in the case of one Abbey Hospice patient who eats breakfast at the Waffle House every morning. If she doesn’t eat well or needs help getting back to her car, the waitresses call her family. (Atlanta Hospital News, 4/2006)

* Much of the work of the Ethics Institute of the University of New Mexico’s Health Sciences Center is focused on end-of-life issues. Anne Simpson, director of the Institute, says, “We’re all going to die. But we do not address it. It just amazes me.” To get people to discuss such issues, the Institute offers, in addition to an advance directive form, a “values history” which enables people to talk about what’s important to them in life and what they want at death. (The Albuquerque Tribune, 4/13)

* Dr. Joseph Fennelly, the physician who cared for Karen Ann Quinlan, says, “The best way to address compassionate end-of-life care is to develop pathways and algorithms that direct and control caretaker decisions.” Fennelly writes that “Thirty years after the first right- to-die decision helped resolve Karen's plight, there exists more compassionate care. It has helped return meaning to medicine by resurrecting the centrality of the physician-patient relationship.” (The Star-Ledger, 3/31)

* CBS’s The Early Show featured a segment on methadone, now being prescribed as a painkiller, and the headline for the show was “Methadone kills more children than any other drug.” Reporter Tracy Smith says that methadone “is increasingly being prescribed as pain medicine in place of headline-making drugs like OxyContin. Teenagers can find it in their parents’ medicine chests, sometimes with fatal results.” Jim McDonough, former director of the Florida Office of Drug Control, says, “The one prescription drug that keeps going up in terms of the absolute numbers of death and the rates of inquiries, particularly for children, is methadone.” (CBS’s The Early Show, 4/10)

* Grace Farnan, a 12-year-old from South Hamilton, Massachusetts, has received the Second Annual Alexandra Scott Butterfly Award. The award was created by Volvo Cars of North America to “honor young heroes who do the extraordinary in the areas of safety, quality of life and environment.” Grace’s grandmother died two years ago while in hospice and the care given to her inspired Grace to become the Hospice of the North Shore’s youngest volunteer. The award was named for Alex Scott, an eight-year-old cancer patient who raised money for pediatric cancer research. Her lemonade stands “inspired a grassroots fundraising effort that raised $1.4 million in 2004 alone.” (Motor Trend, 4/14)

* Syndicated columnist Froma Harrop says that the time has come for a frank conversation about who pays for end-of-life care. Harrop writes, “Medicaid, the health-insurance plan for the poor, is supported by federal and state taxpayers. Medical technology can keep people with no hope of recovery floating between life and death for decades. The taxpayers have a right to set limits on how much of this they will finance.” Harrop says that if taxpayers do not feel obliged to spend large amounts of money caring for people who will never wake up, “then the time has come to question whether even airtight living wills should be the last word.” (The Seattle Times, 4/11)

* Dr. Ravindra Nathan writes of a 90-year-old patient of his whose relatives, rather than seeking palliative care, insisted on surgery to remove a large, probably malignant, abdominal mass. After a very rocky post-surgical period, she died six days after admission, having accrued a hospital bill of more than $95,000. Nathan says she probably didn’t want that but didn’t make her wishes clear with an advance directive or healthcare proxy. Nathan says, “There’s no point indulging in expensive last-ditch efforts to try to save a life that’s beyond salvage” and that “conversations about death and dying are supremely difficult, but we must initiate them.” (Medical Economics, 3/3)

Thanks to Kathy McMahon and Don Pendley for contributions.

Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2006. Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division. Ask your insurance agent to visit their website at www.hccis.com.