Home Health & Hospice Week

While some hospice decisions are simple, figuring out which medications you should cover isn't -- and that's an issue that's fast on the road to becoming a compliance hot spot.

"It's just a matter of time" before Medicare contractors target the issue, predicts attorney Mary Michal, with Reinhart Boerner Van Deuren in Madison, Wis. That's because hospices that don't pick up the tab for medications could push the expense onto Part D, which would cost the government a lot of money, she cautions.

Never fear: Following these key principles can help you navigate the gray areas for covering medications:

"Medicare requires that hospices pay for medication related to the terminal diagnosis and its related conditions," says Joy Barry, principal of Weatherbee Resources Inc. in Hyannis, Mass.

Thus, if someone has a long-standing history of mental illness for which he's been receiving medications, then that may be viewed as unrelated to the terminal illness, says attorney Meg Pekarske, also with Reinhart Boerner Van Deuren.

Exception: "But if the person had a history of depression, which resurfaces when he is dying, that may be related to the terminal illness -- and thus, antidepressants would be included in the hospice coverage."

The medications provided by hospice are used palliatively to manage the patient's pain and symptoms.

And oncologists may inform patients that their chemotherapy is "palliative," says Barry. However, the hospice medical director determines whether the treatment is truly palliative, she points out.

Answer this key question: What is the goal for the patient still on chemotherapy? If it's intended to shrink the tumor and manage symptoms, then the chemotherapy is palliative -- "even if it is psychologically rather than physiologically palliative," says Barry. Yet "some oncologists may find it difficult to stop chemotherapy or may be averse to having a conversation with the patient about his limited prognosis and treatment options," she says.

Resolution: Such cases may present an ethical challenge for the hospice to resolve, says Barry. "For example, the hospice physician may need to facilitate a conversation with the oncologist, patient, and/or family about the patient's prognosis, treatment options, and goals of care."

The distinction between palliative and curative is getting more difficult to make for some exorbitantly expensive chemotherapies, cautions Mary Lynn McPherson, professor and vice chair at the University of Maryland in Baltimore's Department of Pharmacy Practice and Science. "For example, a tyrokinase inhibitor for lung cancer appears to make terminally ill lung cancer patients feel a bit better," she says.

The way out: "It's appropriate," Michal says, for the hospice to have a formulary designating what it thinks is appropriate therapy "where it'd be unusual for a certain medication to be used outside the formulary."

This will keep you or your hospice from having to make each decision on your own.

Keep in mind: When dealing with an outlier medication, you'd ask as part of individualized care planning: "Is this medication the only way to palliate pain and symptoms?"

If a less expensive treatment hasn't relieved the patient's pain and advancing symptoms, says Barry, "the hospice can move up the ladder to a more aggressive treatment approach."

Bottom line: These are patient-by-patient and organization-by-organization decisions that "should be facilitated by the hospice physician in consultation with the [interdisciplinary group] and the patient's attending physician, if there is one," Michal stresses.