Hospice vs. skilled nurs­ing

Re­im­burse­ment’s role in hospice vs. skilled nurs­ing

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Too many dy­ing el­derly pa­tients are go­ing into skilled-nurs­ing fa­cil­i­ties af­ter leav­ing the hospi­tal, ex­perts say, and Medi­care’s re­im­burse­ment ap­proach for nurs­ing homes and hospice care is largely the rea­son.

Medi­care’s re­im­burse­ment struc­ture gives se­ri­ously ill and pos­si­bly dy­ing Medi­care pa­tients and their fam­i­lies a choice for the pa­tient to ei­ther go into a nurs­ing home for skilled nurs­ing or en­ter hospice care af­ter leav­ing the hospi­tal. Be­cause the Medi­care hospice-care ben­e­fit doesn’t in­clude liv­ing ac­com­mo­da­tions, many pa­tients choose a skilled-nurs­ing fa­cil­ity even though a prog­no­sis that death is im­mi­nent means hospice treat­ment would likely be a bet­ter op­tion.

“It’s kind of a sad state of af­fairs,” says Can­dis Ar­mour, ex­ec­u­tive di­rec­tor of So­lari Hospice Care, Las Ve­gas. Pa­tients who would pre­fer the end-of-life care that hospice of­fers—ser­vices that aim to man­age pain and limit treat­ments and pro­ce­dures that of­fer lit­tle ther­a­peu­tic ben­e­fit and can be pro­vided at home—of­ten end up go­ing into a skilled-nurs­ing fa­cil­ity, which es­sen­tially has the op­po­site ap­proach, and seeks to im­prove the pa­tient’s health, Ar­mour says.

“The pa­tient in the skilled-nurs­ing fa­cil­ity may have to agree to things they don’t want,” Ar­mour says.

The is­sue has been dis­cussed in el­der-care cir­cles for years, but a study pub­lished on­line last Oc­to­ber in the Ar­chives of In­ter­nal Medicine quan­ti­fied the prob­lem. The au­thors of the study, “Use of the Medi­care posthos­pi­tal­iza­tion skilled nurs­ing ben­e­fit in the last 6 months of life,” sought to iden­tify pat­terns of care in­volv­ing the use of skilled-nurs­ing fa­cil­i­ties and hospice care.

Among the re­sults was a find­ing that roughly one in 11 se­niors died while in a skilled-nurs­ing fa­cil­ity, a num­ber the au­thors found to be “strik­ingly” high. The find­ing sug­gests that some pa­tients are go­ing into skilled-nurs­ing fa­cil­i­ties to re­ceive end-of-life care, which is con­trary to the mis­sion of those fa­cil­i­ties, says Dr. Kather­ine Aragon, one of the au­thors and a pal­lia­tive-care physi­cian for Lawrence (Mass.) Gen­eral Hospi­tal.

Stay­ing home

The au­thors also found that Medi­care ben­e­fi­cia­ries liv­ing in their homes or else­where in the com­mu­nity were more likely to die in a nurs­ing home and less likely to die at home—where most pa­tients would rather be—if a pa­tient re­ceived care in a skilled-nurs­ing fa­cil­ity at some point in the last six months of life.

Among se­niors who were liv­ing in the com­mu­nity and had re­ceived the skilled-nurs­ing ben­e­fit, 42.5% died in a nurs­ing home, 10.7% died at home, 38.8% died in a hospi­tal and 8% died else­where. That con­trasts sharply with re­sults for se­niors liv­ing in the com­mu­nity who had not re­ceived the skilled-nurs­ing fa­cil­ity ben­e­fit. In that group, 5.3% died in a nurs­ing home, 40.6% died at home, 44.3% died in a hospi­tal and 9.8% died else­where.

“This has been a prob­lem for­ever,” says Carla Brave­man, vice pres­i­dent of home and com­mu­nity ser­vices at not-for-profit El­liot Health Sys­tem, Manch­ester, N.H. “When the pa­tient most needs (hospice), we can’t be there be­cause of a pay­ment is­sue.”

The Medi­care long-term-care pay­ment struc­ture gives ev­ery­one in­volved—ex­cept the hospice-care provider—rea­sons to push for a se­verely ill pa­tient pos­si­bly near the end of life to go into a skilled-nurs­ing fa­cil­ity even though hospice care might be the pre­ferred set­ting.

Though lim­ited to 100 days—with co­pay­ments kick­ing in af­ter 20 days—the Medi­care skilled-nurs­ing ben­e­fit in­cludes 24-hour over­sight, and room and board and must fol­low a min­i­mum three-day hos­pi­tal­iza­tion. El­derly pa­tients leav­ing the hospi­tal with the prog­no­sis they don’t have long to live may need the kind of high-at­ten­tion care that a spouse or other fam­ily mem­ber is un­able or un­will­ing to per­form.

In those cases, ad­mis­sion to a skilled-nurs­ing fa­cil­ity as a Medi­care pa­tient might seem like an at­trac­tive alternative when a pa­tient doesn’t have a fam­ily mem­ber able or will­ing to pro­vide near-con­stant as­sis­tance. Hospice of­fers lim­ited re­spite ser­vices to care­givers.

The pa­tient and fam­ily also might not have the fi­nan­cial re­sources to pay for pri­vately funded non­skilled nurs­ing-fa­cil­ity care—also known as cus­to­dial care—that would al­low the pa­tient to re­ceive Medi­care hospice care in a nurs­ing home stay. Ar­mour says it would cost about $6,000 a month to pay pri­vately for a nurs­ing-home stay. Even if it’s only for a month or two, many pa­tients and fam­i­lies can’t af­ford it or don’t want to pay that much, mak­ing Medi­care-cov­ered skilled-nurs­ing fa­cil­ity care more at­trac­tive be­cause it costs them noth­ing.

Un­der rare cir­cum­stances, a pa­tient can be treated in a skilled-nurs­ing fa­cil­ity for one con­di­tion while still on the hospice ben­e­fit for an­other, but those pa­tients made up less than 1% of hospice pa­tients in the study.

One op­tion for hospice-el­i­gi­ble peo­ple leav­ing the hospi­tal and need­ing shel­ter is Med­i­caid, which will pay for nurs­ing home care—but only if they have de­pleted all their as­sets. Ap­ply­ing can be a lengthy and te­dious process, and ap­proval for those who qual­ify of­ten wouldn’t come quickly enough for them to en­ter the nurs­ing home be­fore they die, Brave­man says.

In­dus­try ex­ec­u­tives con­tacted for this story, in­clud­ing Brave­man, don’t point the fin­ger at skilled-nurs­ing fa­cil­i­ties, even though they may ben­e­fit from the sit­u­a­tion by get­ting pa­tients they might not nor­mally treat.

“I wouldn’t nec­es­sar­ily blame the skilled-nurs­ing fa­cil­i­ties,” Brave­man says. “There’s no mech­a­nism for pay­ment for the nurs­ing homes.”

The Amer­i­can Health Care As­so­ci­a­tion, a nurs­ing home in­dus­try group, es­ti­mated that the Medi­care Part A skilled-nurs­ing re­im­burse­ment is on av­er­age $467 per pa­tient a day, in­clud­ing any co­pay­ments but not in­clud­ing Medi­care Ad­van­tage Part C pay­ments. Hospice providers, mean­while, are paid a base rate of $153 a day in the cur­rent fed­eral fis­cal year, but can get as much as $896 a day dur­ing a “cri­sis,” ac­cord­ing to the Medi­care Pay­ment Ad­vi­sory Com­mis­sion. The CMS de­fines a cri­sis as a sit­u­a­tion in which the hospice pa­tient needs at least eight hours of con­tin­u­ous med­i­cal care to ease pain or man­age acute symp­toms, and must mainly be pro­vided by a li­censed nurse. Both hospice rates are sub­ject to ad­just­ment for re­gional wage dif­fer­ences.

Na­tion­ally, Medi­care paid $31.8 bil­lion for skilled-nurs­ing fa­cil­ity care in 2011 and $27 bil­lion in 2010, ac­cord­ing to MedPAC. Medi­care paid $13 bil­lion for hospice care in 2010, the lat­est year for which data is avail­able.

Sen­tara Health­care, Nor­folk, Va., avoids the fi­nan­cial in­cen­tive con­flicts be­tween hospice and skilled-nurs­ing care be­cause it of­fers both types of care, says Bruce Robert­son, pres­i­dent of Sen­tara Life Care, the sys- tem’s long-term-care di­vi­sion.

Sen­tara is a pro­po­nent of hospice, and re­cently opened an in­pa­tient hospice fa­cil­ity in Vir­ginia Beach, Va., within an as­sisted-liv­ing fa­cil­ity. The hospice will care for Medi­care hospice pa­tients liv­ing in the home who need the Medi­care pro­gram’s short-term hospice ben­e­fit, a spokesman says. The typ­i­cal stay would be five to seven days, he says. If the hospice fa­cil­ity is suc­cess­ful, Sen­tara will con­sider adding one at an as­sisted-liv­ing fa­cil­ity in Nor­folk, Robert­son says.

Changes pro­posed

But hospice care is not uni­ver­sally praised. Dr. Peter Bol­ing, a pro­fes­sor and chair­man of ge­ri­atric medicine at Vir­ginia Com­mon­wealth Univer­sity, says that in his ex­pe­ri­ence, the hospice pro­to­cols when fol­lowed strictly may lead to pa­tients in­ap­pro­pri­ately en­ter­ing hospice. As he has gained clin­i­cal ex­pe­ri­ence treat­ing se­ri­ously ill pa­tients, he says that he has cho­sen to treat some pa­tients who meet the cri­te­ria for en­ter­ing hospice who have got­ten bet­ter. The is­sue of find­ing the moment in time when there’s no hope of re­cov­ery left is a dif­fi­cult one, he says.

Mean­while, some hospice providers are re­port­edly un­der scru­tiny from the fed­eral government for keep­ing pa­tients for too long. Kaiser Health News re­ported last week that at least one and prob­a­bly more hospices are be­ing ex­am­ined be­cause too many of their pa­tients are not dy­ing, lead­ing to ex­tended re­im­burse­ment.

One so­lu­tion to the hospice vs. skilled-nurs­ing de­bate calls for Medi­care to of­fer a blended ben­e­fit of some sort in which a skilled-nurs­ing stay can ac­com­mo­date hospice care as well.

“Pay­ment sys­tems need to put the pa­tient first,” says Co­rina Tracy, se­nior vice pres­i­dent of na­tional op­er­a­tions for Hospice Com­pas­sus, a for-profit hospice-care provider based in Brent­wood, Tenn., with more than 50 lo­ca­tions. If they need both, they should get both, Tracy says.

“I think hospice is a fan­tas­tic pro­gram,” but it doesn’t of­fer com­plete care, says Dr. David Gif­ford, se­nior vice pres­i­dent of qual­ity and reg­u­la­tory af­fairs at the AHCA. To have Medi­care pay for hospice care to pa­tients in a nurs­ing home could be ben­e­fi­cial, he says.

How­ever, ma­jor changes to the hospice ben­e­fit in the cur­rent fis­cal en­vi­ron­ment seem highly un­likely, Ar­mour says. “Medi­care is look­ing to cut things, not bring on new ben­e­fits.”

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