New Medicare hospice rules aim to boost physicians' role

Washington -- Medicare, for the first time in 25 years, has updated the rules for hospice physicians.

The Centers for Medicare & Medicaid Services in June released final conditions of participation for hospice professionals. The new guidelines, the only overhaul of the regulations since Medicare first offered the benefit in 1983, will take effect on Dec. 2.

Some of the most significant changes are in the area of patient rights. The document states that patients who choose palliative care over curative treatments have the right to participate in developing their treatment plans. This includes access to effective pain medications, the ability to choose one's own physician and the option to refuse treatment.

Upon choosing the hospice benefit, patients must receive initial medical assessments within 48 hours and comprehensive evaluations within five days. Assessments must be updated at each 15-day interval after that. Currently, there are no rules detailing when these reviews must be done. Hospice patients also must receive full medication profiles for their conditions.

CMS officials decided to update the participation rules because increasing numbers of Medicare patients are choosing hospice. Nearly 1 million Medicare beneficiaries receive hospice care from more than 3,000 hospices in the U.S.

"End-of-life care has changed markedly in the past 25 years, and it is time to update our regulations to reflect advances in medicine and hospice industry practices, as well as patient rights," said Kerry Weems, acting CMS administrator.

The National Hospice and Palliative Care Organization applauded the regulation update. "The new [conditions] will ensure a framework of quality that benefits patients, families and the organizations providing care at life's end," said its president and CEO, J. Donald Schumacher.

For physicians who practice in the hospice and palliative care setting, the changes likely will not drastically change the way they go about treating patients, said Porter S. Storey, MD. He's a hospital-based palliative care specialist in Boulder, Colo., and the American Academy of Hospice and Palliative Medicine's executive vice president. CMS acknowledged, for instance, that many hospice patients are already very involved in their treatment plans.

Although the changes are not revolutionary, they are evolutionary for the physicians involved in end-of-life care, and this evolution has already started, Dr. Storey said.

"They clearly intend for hospice physicians to be much more involved in the care of patients," he said. "In the past it was possible for a small hospice to just employ a doctor to come by once a week and sign papers. Those days are really over."

For example, Medicare will require, for the first time, that hospices develop quality-assessment and performance-improvement programs and that their physicians participate in the process. Most physicians will welcome this opportunity to become more involved in improving outcomes, Dr. Storey said.

However, stricter requirements on patient assessments and medication consultations will involve more administrative expense. This could potentially exacerbate the conflict that sometimes occurs between physicians who provide palliative care and hospice administrators who want to keep overhead low, Dr. Storey said.

Still waiting for the revolution

While the new conditions of participation are designed to acknowledge the changing face of hospice care in Medicare, nothing in the new regulations modifies the way that the program pays for hospice care and allows patients to access it.

Physicians such as Dr. Storey have been calling on the government to overhaul the payment and eligibility rules for hospice, a process that would take years to accomplish.

Medicare pays a base of about $135 per patient per day for home-based care and allows beneficiaries to access the benefit if two physicians attest that the patient has six months or less to live if the illness runs its usual course. Payment is about $600 per day for patients in hospice facilities.

The hospice payment system still leaves many patients in hospitals who could benefit from hospice services and forces many beneficiaries to bounce back and forth between the hospice and hospital settings, Dr. Storey said. If the hospice benefit paid at a higher rate for more complex patient conditions and became available to patients undergoing active treatment, more beneficiaries could receive more of their needed services through the hospice rather than remain in flux.

Many expensive cancer drugs, for instance, provide a palliative benefit to patients and not just a curative one, but hospices are generally unable to provide them because the payment schedule makes them unaffordable, he said.

Because hospice care on the whole is much less costly than hospital care, it's in Medicare's best financial interests to promote hospice as a more attractive, accessible benefit, Dr. Storey said. "One of the reasons we keep arguing that CMS should be a little bit more generous ... is because keeping patients in the 'going back to the hospital for every problem mode' is not the economical way to help them out."

The Medicare Payment Advisory Commission, however, said in a June report that more hospices are hitting the program's spending cap on individual patients, meaning that costs are approaching hospital levels.

The panel recommends that Congress overhaul the payment system to remove the incentive for hospices to be more profitable by seeking patients who will have longer episodes of care.