Eligibility for hospice care under Medicare requires a terminal prognosis of six months or less to live, assuming that the disease follows its normal course. This must be certified in writing by two doctors -- the patient's attending physician and the hospice's medical director. Increasingly, however, a third party has inserted itself into these difficult decisions: a government agent responsible for reviewing claims submitted to Medicare by hospices or one of a growing number of Medicare watchdog agencies authorized to review and overturn hospice claims after they've been paid.
When I set out to examine the impact of the government's scrutiny of hospices' admissions practices for the Hospice Compliance Letter newsletter, I found that hospices are spending more time and money trying to satisfy the government's second guessing of their physicians' admitting decisions. Some are becoming too careful in who they will admit, turning away deserving patients or performing invasive diagnostic tests that are unlikely to change the patient's course of treatment -- merely satisfy the government that the patient in fact is terminally ill. And yet other hospices seem to be flying under the radar, ignoring or blissfully unaware of the heightened government scrutiny directed at their peers.
While the government is penalizing hospices for admitting patients "too soon," no other health professionals are held accountable for the large numbers of patients who are referred to hospice too late -- in the last seven days or less before they die, past the point when the hospice team could work its magic to make the dying experience more comfortable and peaceful for the patient and family. But we also know there are some hospices out there misusing the hospice benefit, making it their practice to admit large numbers of patients who are not actually dying. We don't know how many hospice are abusing the benefit in this way, and we can't figure out how they persuade patients to consent to a benefit designed for the terminally ill when they are not terminally ill.
In a special report on hospice eligibility, which we are releasing to the public at www.hospicecompliance.net, we explore the medical and emotional difficulties of making clear and accurate terminal prognoses and the troubling nuances of hospice payment and regulation under Medicare. We ask the question: How does an industry such as hospice, advertised as a compassionate and idealistic form of care for vulnerable dying patients, hold all of its members to the same idealistic standards -- while more forcefully advocating for the needs of those patients? We believe these issues need to be openly discussed within the hospice industry and larger health care system, by the government and, eventually, by all Americans who will some day want and need this service in the final phases of their lives. But only if the government says they are sufficiently terminally ill to qualify for hospice care.