Medicare hospice benefit centers for medicare and medicaid services

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Total Medicare Part A payments per patient window were computed as the sum of hospital and nonhospital payments. Of the total, 10 percent were added to account for Part B payments. Average conventional care per diem reimbursements were computed for each window by dividing total reimbursements by the number of days in the window. Table 6 presents the net Medicare hospice savings per day by various assumed lengths of stay and Table 7 presents the same data by the three major hospice provider types.

An estimate of the relative difference between the hospice and conventional care was obtained by dividing what would have been reimbursed in benefit and regular Part A payments for a hospice patient had enrollment occurred at 5 days before death, 10 days, etc.

A ratio of 1. Values greater than 1. The aggregate figures in Table 6 mask the large differences in savings ratios among hospice provider models. Freestanding and home health-based hospices generally saved Medicare money relative to conventional cancer patient care for patients enrolled 30 days or less.

Table 7 shows the difference in savings among the four categories of hospices. However, the hospital and SNF-based hospices saved only under the relatively generous assumption B.

Thus far, the magnitude of the estimated total Medicare savings or costs associated with the benefit has been small relative to the total Medicare expenditures. If the more generous assumption B was used, a savings ratio of 1.

Regardless of the assumptions used, the estimates of net reimbursement effects are well below 0. The Jack Martin and Company analyses of the prognoses of the patients treated by the three types of noncertified hospices show that the independent and community-based hospices have a lower percent of patients with a prognosis of more than 6 months to live 2 percent and 5 percent than the hospital-based hospices including skilled nursing facilities that have almost 15 percent of their patients in the longer prognosis category 10 Table 8.

Comparable information is not available on the prognoses of the Medicare hospice patients. Of the noncertified, community home health agency-based hospices studied, 29 percent of their patients were discharged alive, compared with Of Medicare hospice patients, 5 percent revoked the benefit before dying. There is little difference among the three types of noncertified hospices with respect to either patient urinary or fecal incontinence. There is only a small amount of variation among the hospice types with respect to the percent of patients with immobility in walking, ranging from Although there is little difference in the average percent of noncertified hospice patients with a prognosis greater than 6 months between cancer and noncancer patients as a whole 8.

Hospital-based noncertified hospices are more likely to have cancer patients with a prognosis of greater than 6 months to live, whereas community and independent hospices are more likely to have noncancer patients with a prognosis greater than 6 months. There is little difference between the percent of cancer and noncancer patients discharged alive for both community home health agency-based hospices 29 percent and 26 percent and independent and freestanding hospices 8 percent and 9.

However, for the hospital and skilled nursing facility-based hospices, 32 percent of the noncancer patients are discharged alive, compared with 14 percent of the cancer patients.

In noncertified hospices, patients with noncancer diagnoses are more likely to have longer hospice stays The Joint Commission on Accreditation of Healthcare Organizations conducted a research study using the Commission's hospice accreditation program standards and criteria as the survey guide Joint Commission on Accreditation of Hospitals, Both a mail survey of a sample of hospices and onsite surveys of 60 Medicare certified hospices and 60 noncertified hospices were conducted.

The degree of hospice compliance with the numerous Joint Commission Standards used a rating scale. Guidelines in decisionmaking are used by surveyors. For example, for a rating of 1 substantial compliance , the rating guidelines state:. This is the highest rating possible and should reflect the hospice's full compliance with the intent of the standard. If total compliance has been evident for only days before survey, the score may be given with a written recommendation.

Analyses of the data reveal that, on average, Medicare certified hospices provide more comprehensive services, are providing care with more professional and appropriately trained staff, and have better processes of care provision than do noncertified hospices Longo, McCann and Ahlgren, The major findings of the Joint Commission on Accreditation of Hospitals study follow. Medicare certified hospices are larger than most noncertified hospices, both in terms of home care patient census and annual budgets.

Although the average monthly inpatient census is similar 3. However, 79 percent of the noncertified hospices, compared with only 37 percent of the certified hospices, had budgets this low Longo, McCann, and Ahlgren, A similar proportion of both certified and noncertified hospices provide intermittent less than 8 hours nursing care in both the home and inpatient settings.

However, 97 percent of certified hospices are reported to provide continuous nursing care in the home, compared with only 46 percent of the noncertified hospices. A significantly greater proportion of certified programs specify minimum education and experience requirements for their nursing care providers than do noncertified programs 90 percent, compared with 67 percent Longo, McCann, and Ahlgren, Hospice nursing time is spent similarly for both certified and noncertified hospices.

Approximately one-third of the nurse's time in the home is spent conducting clinical, technical nursing interventions; another one-third is spent providing psychosocial support; and about one-fourth is spent in patient and family teaching. For both certified and noncertified hospices, home visits were most frequently made in response to patient respiratory distress and impending death. All hospices are unlikely to make home visits for decreased mobility, anorexia, and skin integrity problems, all of which are symptoms of the expected physical decline of dying patients and do not signal acute conditions requiring intervention.

Pain and respiratory distress, followed by impending death, and patient and family stress are the most frequent reasons for inpatient admissions by all hospices.

A significantly greater proportion of certified hospices 92 percent provide nursing services that are based on a nursing assessment than do noncertified hospices 65 percent. Similarly, certified hospices have a higher percent 77 percent of documentation of nursing services that is representative of current practice than do noncertified hospices 54 percent.

Certified hospices are also more likely 58 percent to have documentation of nursing services that are goal-directed in accordance with the interdisciplinary team care plan than are noncertified hospices 40 percent. Approximately 90 percent of all certified and noncertified hospice medical directors are fully board certified in their specialty. Certified hospices are more likely to use their medical directors to provide attending physician services than are noncertified programs.

Almost all percent hospices report that attending physicians are responsible for providing the admitting diagnosis, prognosis, and current medical findings; medication and treatment orders; and other pertinent orders regarding the patient's terminal condition.

However, considerably fewer of the hospices require the attending physicians to be responsible for approving the interdisciplinary team care plan 83 percent certified and 67 percent noncertified hospices. Certified hospices were found to be more likely than noncertified hospices to have attending physicians communicate with the interdisciplinary teams, document physical examinations, and provide diagnostic and therapeutic orders. Hospices emphasize intervention for psychological, economic, and social problems associated with terminal illness.

Noncertified hospices are more likely than certified hospices to provide psychosocial care in the home through contractual or informal arrangements.

Noncertified programs are significantly less likely to have adequate written policies specifying the minimum education and experience required of psychosocial care providers and are significantly less likely than certified programs to have an adequate number of individuals providing psychosocial services that have appropriate education, training, and experience.

Also, those who supervise the psychosocial care providers in certified hospices are significantly more likely to have advanced degrees and appropriate clinical experience than those supervisors in noncertified hospices.

However, problems with psychosocial service documentation are noted for both certified and noncertified hospices. Noncertified hospices are more likely 38 percent than certified programs 20 percent to provide spiritual services through informal arrangements with community clergy and are significantly less likely 45 percent than certified hospices 86 percent to have adequate written policies stating the minimum education and experience required for spiritual service providers on the team.

Both certified and noncertified hospices have difficulty with the documentation of spiritual services. An important component of hospice philosophy is the provision of bereavement care to survivors for at least 1 year following the death of the patient. Only 66 percent of certified hospices and 59 percent of noncertified hospices have bereavement services available for that period of time.

JCAH found that an adequate process for the assessment of survivor needs and a referral process for pathological grief reactions was present in 58 percent of certified hospices and in 39 percent of the noncertified hospices. Certified hospices are more likely than noncertified hospices to provide respite care, physical therapy, occupational therapy, speech therapy, and dietary and nutritional counseling to hospice patients and families.

These services are more frequently provided by certified hospices through contractual arrangement than noncertified hospices. Certified hospices are significantly more likely 60 percent to have an interdisciplinary team care plan for each patient and family than are noncertified hospices 25 percent.

Almost all 92 percent of the certified hospices, compared with only 59 percent of the noncertified hospice programs, have interdisciplinary team care plans completed within the first 5 days after home care admission. Both certified and noncertified hospices have difficulty meeting the standards requiring that the care plan be based on interdisciplinary team assessments. About one-third of both certified and noncertified hospices 30 percent and 36 percent, respectively did not have adequate evidence of patient and family informed consent.

Only 22 percent of the certified hospices and 12 percent of the noncertified hospices have written policies and procedures specifying their position on patient resuscitation in the home care setting, including appropriate orders by the attending physician and documentation in each patient's medical record.

About 70 percent of both have these written policies and procedures in the inpatient setting. Practically all hospices use volunteers. However, one-third of noncertified hospice programs are volunteer-intensive greater than 80 percent of the services provided by volunteers , compared with only 4 percent of Medicare certified hospices. The way volunteer help is used is similar for both certified and noncertified hospices: about one-half 57 percent of volunteer time is assigned to general support and assistance duties; 12 percent is assigned to administrative office duties, 10 percent is assigned to bereavement care, and 8 percent is assigned to direct patient care for professional services.

Both certified and noncertified hospices are similar in their orientation and training of volunteers, although certified hospices are more likely to include medical emergency procedures in their volunteer training. Using a weighting procedure, summary scores of compliance were calculated for all hospices that participated in onsite surveys. Each hospice was assigned to one of three categories: substantial compliance good ; partial or less compliance key standard grey zone ; and tentative nonaccreditation.

On average, more than 70 percent of the noncertified hospices studied had overall compliance scores which placed them in the tentative nonaccreditation category, compared with 12 percent of the certified hospices Table 9. Hospital, skilled nursing facility, and home health agency-based hospices averaged 69 percent that tentatively would not have been accredited, compared with 80 percent of the independent and freestanding hospices.

All of the noncertified programs were rated considerably lower than the certified hospices as a whole. The independent noncertified hospices had the highest percentage 80 percent of poor scores.

Although the Medicare hospice benefit got off to a rather slow start, both in terms of the number of hospices applying for certification as Medicare providers and the number of Medicare beneficiaries electing the benefit, the growth of the program has been steady. The number of certified hospices has increased from at the end of the first year to at the end of the fourth year of the benefit.

It is estimated that about 1, hospices may ultimately apply for certification as a Medicare provider. The percent of U. Almost one-half of all home health agency-based hospices were certified in , compared with 14 percent of hospital and skilled nursing facility-based hospices and 21 percent of freestanding hospices.

The reluctance of hospice administrators to apply for and participate in the Medicare hospice program has been based primarily on the uncertainty of associated financial risks. In particular, a sample of administrators mentioned concern about the cap on average aggregate payments and the day reimbursement limit. Actual experience showed that during the first 2 years of the benefit, no hospices exceeded the cap and few exceeded the percent inpatient limit. Independent hospices were more likely than provider-based hospices to express concern that they are financially unable to meet the certification requirements.

This concern may be realistic: about two-thirds of the noncertified hospices studied by JCAH received summary scores that would have resulted in nonaccreditation. About one-third of noncertified hospices are volunteer intensive, compared with only 4 percent of certified hospices.

Although the Joint Commission noted aspects of certified hospice performance that need improvement, they documented that, overall, certified hospices are providing more comprehensive services than most noncertified hospices and are providing services appropriately, as defined by the accreditation standards. Certified hospices are generally using more professional and specially trained staff and using better processes of care than noncertified hospices.

Medicare certified hospices are larger, both in terms of patient census and budgets, than most noncertified hospices. They are employing more systematically and uniformly better administrative procedures believed to contribute to higher quality of care. Certified providers were found more likely to have documentation that demonstrated that the nursing services were goal directed and that the treatment plans were developed on the basis of interdisciplinary team assessment.

Certified hospices were found to be more likely than noncertified hospices to have the attending physicians communicate with the interdisciplinary teams, to document physical exams, and to provide diagnostic and therapeutic orders.

Both certified and noncertified hospices were found to have problems with documentation of psychosocial, spiritual, and bereavement services. About one-third of both certified and noncertified hospices did not have adequate evidence of informed patient consent, and few hospices have policies on resuscitation in home care settings.

During the first 2 years of implementation, the costs of the Medicare hospice benefit were modest. Final analyses, using 3 years of data, will be available during the summer of In summary, the hospice program, as of , continues to grow, both in terms of number of providers, number of beneficiaries, and average Medicare expenditures. Further analyses from the hospice program evaluation project will shed more light on the progress of this important program.

The financial data are derived from a subset of beneficiaries for whom enrollment, billing, and death data are complete. Therefore, there is some difference among the tables regarding the numbers of hospice patient presented.

Because it is not always possible to determine whether the differences between claimed and reimbursed amounts can be applied equally to each of the four types of daily reimbursement rates, charge data are used. Prognosis was one of the patient variables with the highest rate of missing data.

Health Care Financ Rev. Feather Ann Davis. Copyright and License information Disclaimer. Copyright notice. Abstract In this article, an overview of the Medicare hospice benefit is presented and selected preliminary findings from the Medicare hospice benefit program evaluation are provided. Background Hospice movement in the United States Although the hospice concept of a place to die is ancient, the convergence of clinical thought about pain control with a philosophy of humane palliative care for the dying occurred during the 's.

Variations in services and organization Many forms of hospice emerged: a few facilities similar to the English freestanding hospice model, hospital-affiliated programs, community-based models, and home care agency services Munley, ; Longo, McCann, and Ahlgren, Medicare hospice benefit Despite uncertainties regarding the costs, Congress judged the benefits of hospice care sufficiently great to warrant enactment of Public Law , section , in August , thereby creating a Medicare hospice benefit.

Major benefit provisions Election All Medicare Part A beneficiaries are eligible for hospice care for up to two day periods and one subsequent day period if the beneficiary's attending physician and hospice physician certify that a patient is terminally ill, that is, has a life expectancy of 6 months or less, and the patient has elected to receive hospice services. Certification and coverage As with all other types of Medicare providers, hospices must receive certification by the Department of Health and Human Services that they meet the conditions of participation in order to be recognized as Medicare reimbursable providers.

Payment method Cost savings were to be encouraged through limits on the average aggregate annual payment per patient, adjusted annually for inflation, and the total inpatient days for which a hospice can receive reimbursement. Table 1 Medicare hospice benefit payment rates and services covered, by category: April 1, Open in a separate window. Evaluation issues and methodologies The major questions specified by Congress in TEFRA concerning the Medicare hospice benefit include the following: Is hospice care in general, and under this or some other Medicare benefit cost effective?

Are certain kinds of services, such as outpatient drugs, nutritional and dietary counseling, and bereavement counseling, adequately financed under the benefit? Evaluation contracts A JCAH survey of structure and process of hospice care describes the hospice industry both Medicare certified and non-Medicare certified as of Preliminary findings Hospice participation Prior to the implementation of the Medicare hospice benefit, representatives of the National Hospice Organization NHO estimated that only about hospices could meet the requirements of the legislation at that time; a similar number was estimated by the Inspector General of the Department of Health and Human Services.

Beneficiary participation The relatively small number of hospices that initially applied for certification is interrelated with the initially small number of Medicare beneficiaries who chose to elect the hospice benefit.

Table 2 Number and percent of Medicare beneficiaries and length of hospice enrollment, by selected characteristics: Fiscal years Reasons for not participating Initially, there was a great deal of uncertainty among hospice personnel regarding the implications of participation in the new Medicare program. Table 3 Hospice charges per Medicare hospice patient, by type of service and hospice: Fiscal years Table 4 Percent of Medicare hospice patient using specified service, by type of service and hospice: Fiscal years Type of hospice and fiscal year Type of service Routine home care Continuous home care Respite inpatient care General inpatient care Physician services Percent Total 89 14 1 27 14 89 11 2 28 13 Freestanding 96 12 1 16 11 92 12 1 19 14 Hospital-based 91 10 3 31 21 84 5 3 34 13 Skilled nursing facility-based 73 2 2 57 7 79 3 3 56 11 Home health agency-based 81 21 1 32 18 92 16 2 22 Table 5 Average Medicare hospice reimbursements and charges, by type of service: Fiscal years These are obtained from the utilization file that contains the subset of beneficiaries who have a hospice election, have final bills, and who died within the fiscal year.

Impact on Medicare Abt Associates, Inc. Table 6 Average Medicare hospice benefit and conventional care reimbursement and net hospice savings per day using two assumptions, by assumed length of stay: Fiscal year Table 7 Net hospice savings 1 per day, using two assumptions, by type of hospice and assumed length of stay: Fiscal year Assumed length of stay Type of hospice Freestanding Hospital-based Skilled nursing facility-based Home health agency-based Assumption A 2 days 1.

Hospice comparisons Patient characteristics The Jack Martin and Company analyses of the prognoses of the patients treated by the three types of noncertified hospices show that the independent and community-based hospices have a lower percent of patients with a prognosis of more than 6 months to live 2 percent and 5 percent than the hospital-based hospices including skilled nursing facilities that have almost 15 percent of their patients in the longer prognosis category 10 Table 8.

Table 8 Percent distribution of noncertified hospice patients, by type of hospice and selected patient characteristics: Patient characteristic Type of hospice Total 4, Community and home health Hospital and skilled nursing facility-based 2, Independent and freestanding 1, Percent distribution Diagnosis Cancer NOTE: The number of hospices in each category is given in parentheses.

Services, staff, and procedures The Joint Commission on Accreditation of Healthcare Organizations conducted a research study using the Commission's hospice accreditation program standards and criteria as the survey guide Joint Commission on Accreditation of Hospitals, Size Medicare certified hospices are larger than most noncertified hospices, both in terms of home care patient census and annual budgets. Nursing services A similar proportion of both certified and noncertified hospices provide intermittent less than 8 hours nursing care in both the home and inpatient settings.

Physician services Approximately 90 percent of all certified and noncertified hospice medical directors are fully board certified in their specialty. Psychosocial services Hospices emphasize intervention for psychological, economic, and social problems associated with terminal illness.

Spiritual services Noncertified hospices are more likely 38 percent than certified programs 20 percent to provide spiritual services through informal arrangements with community clergy and are significantly less likely 45 percent than certified hospices 86 percent to have adequate written policies stating the minimum education and experience required for spiritual service providers on the team.

Bereavement services An important component of hospice philosophy is the provision of bereavement care to survivors for at least 1 year following the death of the patient. Additional services and processes of care Certified hospices are more likely than noncertified hospices to provide respite care, physical therapy, occupational therapy, speech therapy, and dietary and nutritional counseling to hospice patients and families.

It is available to any beneficiary who is diagnosed with a terminal illness, as long as a doctor certifies that they're expected to live less than six months. In most cases, the hospice benefit is provided via Original Medicare Part A , even for beneficiaries who are enrolled in Medicare Advantage plans. But a pilot program began in that allows some Medicare Advantage plans to provide hospice benefits directly to their enrollees.

If you or a loved one with Medicare is in need of hospice care, rest assured that the program provides strong hospice benefits. Your costs will be minimal, and all necessary palliative care will be covered. If treatment is needed for a condition unrelated to the terminal illness, Medicare will continue to provide those benefits just like normal, in addition to the hospice care.

The Medicare hospice benefit also includes inpatient respite care, so that your normal caregiver can have a chance to rest. Centers for Medicare and Medicaid Services. Medicare Hospice Benefits.

Medicare Learning Network. Hospice Payment System. January How to Compare Medigap Policies. Compare Medigap Plans Side-by-Side. December 19, Kaiser Family Foundation. Jun 21, She's held board certifications in emergency nursing and infusion nursing.

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