Eli's Hospice Insider

Published on Wed Jul 18, 2018 PDF

In 2017, 42% of the time the patient did not receive a skilled visit during the last 7 days of life.

Medicare’s hoped-for solution for boosting care levels in the last days of life has yet to materialize, the 2019 proposed rule for hospice payment indicates.

The problem: “We are concerned that many hospice beneficiaries may not be receiving skilled visits during the last days of life,” the Centers for Medicare & Medicaid Services notes in the rule published in the May 8 Federal Register. “In the period of time immediately preceding death, patient needs typically surge and more intensive services are warranted, so we expect that the provision of care would proportionately escalate in order to meet the increased clinical, emotional, and other needs of the hospice beneficiary and his or her family and caregiver(s). The last week of life is typically the period within the terminal illness trajectory that is associated with the highest symptom burden, typically marked by impactful physical and emotional symptoms, necessitating attentive care and engagement from the integrated hospice team.”

The solution: CMS implemented a few changes “with the objective of encouraging visits during the last days of life,” it notes in the rule:

First, it began making Service Intensity Add-on payments in January 2016.

Second, it finalized two new Hospice Quality Reporting Program measures effective April 1, 2017: (1) Hospice Visits When Death is Imminent, assessing hospice staff visits to patients and caregivers in the last week of life; and (2) Hospice and Palliative Care Composite Process Measure, assessing the percentage of hospice patients who received care processes consistent with existing guidelines.

However, the combination of the SIA payments and the new quality measures aren’t remediating this problem — at least not yet. In Fiscal Year 2017, claims data shows that nearly 42 percent of the time the patient did not receive a skilled visit (skilled nursing or social worker visit) during the last seven days of life. That’s only a slight improvement from 44 percent in 2016.

Likewise 20 percent of beneficiaries did not receive a skilled visit on the day of death in FY 2017, which is only a slight improvement from 21 percent in FY 2016.

“We are concerned at the lack of increase in visits to hospice patients at the end of life,” CMS says in the rule. “Beneficiaries appear to be receiving similar levels of care when compared to time periods prior to the implementation of the payment policy reforms, which may indicate that hospices are not providing additional resources to patients during a time of increased need.”

The SIA payment is supposed “to compensate providers for the cost of providing additional, more intensive care at the end of life, in addition to the payment already made for those RHC level of care days that qualify for the SIA,” CMS notes. “We will continue to monitor the provision of hospice services at end-of-life and impacts of the SIA payment and other policies.”

This metric is problematic, notes Judi Lund Person with the National Hospice & Palliative Care Organization. Hospices continue to grapple with the difficulty of predicting death with accuracy, especially for non-cancer diagnoses, Lund Person says. Neuro and other non-cancer diagnosis cases often fail to have a linear trajectory and often have dips and rebound periods which make predicting death challenging.

“We need to really shine the light on this” and boost needed visits in the last days of life, Lund Person tells Eli.