A Two-Tiered Medicare Payment Approach with a Death Bonus?

If we could only get these patients to die on time…

I’m not trying to blast anyone here… I want to be in good standing with everyone if possible, so please don’t take my words as an attack on any individual, but rather the ideas. We are all working to make a better system of care ultimately, but I think we really need to consider what this reform will do. In my view, it is obvious… these new reforms of the CMS Hospice payment structure will diminish the Hospice experience in the long-term by further shortening LOS as well as creating incentives that reward fostering unneeded clinician dependency. In the short-term, many may think that “with shorter and shorter lengths of stay, we will do better financially under this new system.”  This will probably be the case. However, under this two-tiered approach, you can expect LOSs to become even shorter. It is obvious that human beings will alter their behavior in order to be rewarded. Under these reforms, the incentives are fairly clear. Patients will need to behave well, that is die on time, AND need additional care (the Death Bonus) as we expect caregivers to have great anxiety and issues near the transition period due to inadequate caregiver teaching and preparation. Bluntly stated, this is a step backwards…

Not Gaming this Reform – A Chance to Demonstrate Ethics
To optimize Medicare payments under this reform, patients should live 60 days and provide a clear indication of their time of death so that a Hospice can invade a patient’s home for 4 hours a day for the last week of life. Hmmm….  

As Hospice professionals, we would never advise our clients to “game” a payment system. It is unethical if we are truly considerate of the patient/family experience as well as stewards of our nation’s resources. Therefore, Hospices that are aligned with integrity will leave money on the table with this reform and some will be hurt by it when trying to do the right thing with discharged patients.

There are at least two areas an ethical Hospice will be impacted:

#1 – Re-admits
An ethical Hospice will take a beating when it readmits discharged patients when the 60-day “front-end” money has been used up by another provider. An ethical Hospice WILL take these patients despite the lower reimbursement… and will care for the patient with less. Perhaps there is something I don’t know about here… a modifier or “special rule” to fix this? We will soon find out.

#2 – The Death Bonus
This is the Intensity Add-On. It basically incentivizes a Hospice to be in the home or care setting more in the last week of life (up to 4 hours a day, billed at the Continuous Care rate). What is wrong with this? I thought the intention of Hospice care was to empower caregivers and help them be confident in the care they are providing to their loved ones? Hmmm… so if we do a poor job of teaching and preparing caregivers, then they will be dependent upon us, especially as they approach the transition AND WE CAN BILL FOR IT! This is a problem. Hospices will start to design systems that PROMOTE more lengthy visits as death seems more likely. Is this what people want? Some will of course…but this is not great Hospice care. I will say this, IF a Hospice does a great amount of the Intensity Add-On (the Death Bonus), the Hospice is a LOW quality organization as its clinicians are NOT teaching well by adequately preparing caregivers for the patient transition. In fact, I would not even advise a Hospice to build much of a system around the Intensity Add-On! If you do, you are sending a powerful message that you “expect caregivers to be “freaking out” and panicked. I think that it is OK to bill for this time as it is being permitted, but I wouldn’t build a big system around it that encourages the use of the Intensity Add-On! And what about the “sacred experience” of a person dying surrounded by loved ones? Many people do NOT want an “outsider” present during this time. When my Mom died in Hospice, it would have been awful to have any non-family member in the house. An outsider would have “inhibited” us from really being able to let go. After Mom passed, all of us kids just stayed around the bed and talked for more than an hour. It was a wonderful closure experience! Do you think that would have happened with a Hospice person in the hall or the living room? No way! The “sacred experience” of your loved one dying is something that should be determined by the patient and family…not the Hospice. So if the family wants a Hospice person there, bill for it. If they don’t (and this is what your goal should be), don’t be there! We are guests! NEVER stay longer than is needed on any visit! With the Death Bonus, we’ll have Hospice clinicians “waiting around” for people to die because we can bill for it.

Other Considerations
There are other things that must be considered with these reforms:

• The cost to the Medicare System will probably increase, at least in the short-term. This is due to the increasing numbers of short-living patients. So many Hospices will get a financial bump. But these will cost the Medicare System more unless there are further changes or there is a rebasing of rates. We are going to get even better at brink of death care with the reforms. Then, when the increased financial outlays are realized by CMS, we will be hit again with another reform.  
• The reforms COMPLICATE Hospice business. There are costs associated with administering these new rules. The business model will be more complicated. All systems will need to be modified. The review process for the Death Bonus will take additional time, which is likely to delay Hospice payments. Complicated breaks and slows things down. It will cost providers as well as the Medicare system. And the question is “for what?”
• Hospice is beginning to look like other flavors of healthcare. Because Hospice is a bit of “freak” in that it is based on a capitated managed-care model, often people that are familiar with other sectors of healthcare don’t get it. As all human beings tend to favor what they understand. The modifications that we are seeing are steering Hospice to look like what “they” understand.

The Remedy? 
What is the Remedy? It is an elegant and simple solution really. Just keep the traditional Hospice methodology and modify the calculation of the aggregate CAP to a quarterly system with automatic payment cutoffs for those providers that exceed it in any quarter as well as to Hospices that fail to meet the 5% Volunteer requirement. Why put so much emphasis on the Volunteer requirement? Because a community will smoke out low-quality, bottom-feeder Hospices by NOT volunteering! Volunteers “get” which Hospices are high-quality! And it doesn’t make a difference if a hospice is a For-Profit or a Not-For-Profit, people will volunteer for what they perceive as quality! This causes Hospices to have to be engaged in the community and provide a quality experience. Hospice was born on the front porches and in the church basements of this country… by people that received ZERO pay… people that just “cared enough” to improve how people die. Hospice is about the community and I see the role of the community being continually diminished and de-valued with so many Hospices. So if an incentive needs to be altered, here you go!    

MVI clients have signed up with us for a considered opinion. I have offered mine here. You may or may not agree and that is OK. Let the best ideas win regardless of where they come from! We are all part of this dialogue! But let’s not hold onto any inferior ideas because we have an ego-related ideological investment! I’m not saying I’m “right” here and I certainly don’t want to come off as trying to be Mr. Big. I simply care about our Hospice movement a great deal… I am open to change and improvement of course, but not keen on going backwards…

Serving Hospice ~ Andrew Reed