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PROGNOSTICATION AND UPDATED HOSPICE REGULATIONS
IN CARE PLANNING FOR FRAIL ELDERS
Milta Oyola Little, D.O. CMD
Saint Louis University
Speaker Disclosures
Dr. Little has disclosed that she has no relevant
financial relationship(s).
Dr. Little will not be discussing any off-label or
unapproved medications or therapies.
Objectives
• By the end of the session, participants will be
able to
o Describe how trends in hospice utilization affect
patient quality outcomes, Medicare
reimbursement, and the development of models
of care.
o Describe the proposed demonstration projects
and changes to Medicare hospice
reimbursement.
o List available prognostication tools to assist with
clinical decision-making.
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Created By: Medical College of Wisconsin. Available at POGOe.org, Assessed 2/16/14
Medicare Hospice Benefit
• Established in 1982 for high-quality end-of-life care
• Eligibility
o Medicare Part A
o Terminal illness (6 months or less if illness runs its natural course)
o Forgo intensive medical interventions of curative intent
• Benefit Period
o Two 90 day periods, followed by unlimited 60 day periods
o Initial certification by two physicians
o Recertification by hospice physician
Trends in Hospice Use
• In 2012, ~1.5-1.6 million patients received hospice
services
Hospice Care in America. NHPCO Facts and Figures, 2013
Trends in Hospice Use
• Cancer diagnoses now account for less than half of
all hospice admissions
Hospice Care in America. NHPCO Facts and Figures, 2013
Hospice Use in the NH
Miller SC, et al. JAGS 2010; 58:1482-1488
Hospice Use in the NH
•
•
•
•
Better pain management
Fewer hospitalizations
Greater family satisfaction with care at end-of-life
Lower cost across all time periods
Miller SC, et al. JAGS 2010; 58:1482-1488
Kelley AS, et al. Health Affairs 2013; 32(3):552-561
Recent Changes to the
Medicare Hospice Benefit
Medicare is Watching You
“We found that 82% of hospice
claims for beneficiaries in nursing
• OIG Report
facilities in 2006 did not meet
o Federal oversight lacking
Medicare coverage requirements.
o High deficiency rate
Medicare paid approximately $1.8
billion for these claims. …raises
concerns about the services that
• NH Utilization
Medicare
is payingTrends
for and the
o Nebulous
diagnoses
quality
of care that
hospices are
o Increased
Medicare expenditures
providing
to beneficiaries
during
Effectiveness
NH-Hospice collaborations
theirolast
months ofoflife.”
OIG, “Medicare Hospices: Certification and Centers for Medicare & Medicaid Services
Oversight,” OEI-06-05-00260, Apr 2007
OIG, “Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance With
Medicare Coverage Requirements,” OEI-02-06-00221, Sept 2009
How Reimbursement
Currently Works
• All-inclusive per diem rate
o
o
o
o
Routine home care**
General inpatient care
Continuous care
Respite care
• Not adjusted for case-mix or NH setting
• Medicare caps aggregate payments
Huskamp HA, et al. Health Affairs 2010; 29(1):130-135
Hospice Care in America. NHPCO Facts and Figures, 2013
Proposed Changes to
Reimbursement
• Move away from flat per diem rate
Active dying phase
Enrollment
• Consideration for different payment structure for
hospice care in the nursing home (being studied)
Medpac Report to the Congress. Reforming Medicare’s Hospice Benefits
2009; Chap 6:347-376
Medpac Report to the Congress. Reforming Medicare’s Hospice Benefits
2009; Chap 6:347-376
Recent Reimbursement
Changes
The Medicare Hospice Benefit. hospiceactionnetwork.org
• Failure to meet quality reporting requirement will result
in 2% reduction in 2014 Market basket update
o NQF #0209: Pain Management
o Participation in QAPI with >3 quality indicators related to patient care
CMS Federal Register. FY2014 Hospice wage index and payment rate update 2013;
78(152):48234-48281
Recent Regulatory Changes
• Brief Physician Narrative: Effective Oct 1, 2009
• Face-to-Face Encounter: Effective Jan 1, 2011
• 100% Medical Review of Certain Patients: Effective
Jan 1, 2011
• Ineligible ICD-9 codes under “Symptoms, Signs and
Ill-Defined Conditions” and “Mental, Behavioral and
Neurodevelopmental Disorders”
The Medicare Hospice Benefit. hospiceactionnetwork.org
CMS Federal Register. FY2014 Hospice wage index and payment rate update
2013; 78(152):48234-48281
CMS Federal Register. FY2014 Hospice wage index and
payment rate update 2013; 78(152):48234-48281
Proposed Models of Care
Concurrent Care Demonstration Projects
End-of-Life Benefit
Concurrent Care
Demonstration
Curative
Hospice
Care
6 months
Curative
Hospice
Care
No Time Requirement
ACA Sec. 3140
Medicare Hospice Concurrent
Care Demonstration Program
• 3-year projects
• Modification of existing eligibility criteria
o To reduce very short hospice stays (reduce delay in enrollment)
o Test of need for palliative care without strict prognostic requirement
o Greater access for certain underserved groups
• To measure effects of concurrent care on cost,
access, quality of care, and survival
Casarett DJ. JAMA 2011; 305(10):1031-1032
ACA Sec. 3140
Medicare Hospice Concurrent Care
Demonstration Program
• Diagnoses
o COPD, CHF, HIV/AIDS, Cancer
o Fact Sheet
• Limitations
o NH patients not eligible
o Dementia diagnoses excluded
End of Life Benefit
• Modified program for LTC residents
o Drops 6-month prognostic requirement
o Drops requirement to forgo curative treatments
o Combination of palliative and psychosocial-spiritual support
• Supplemental payments made directly to NH
o End-of-life services “carved-in” and adjusted to need
o Provide care directly or contract with local hospice
o NH accountable for quality of care – quality indicators TBD
• Threshold for patient eligibility TBD
Huskamp HA, et al. Health Affairs 2010; 29(1):130-135
Prognostication Issues
Slide used with permission, courtesy of Eric Widera, MD
Dying is Individual
Lynn J, Adamson DM. Living well at the end of life. Adapting health care to
Lunney, J. R. etserious
al. JAMA 2003;289:2387-2392
chronic illness in old age. Washington: Rand Health, 2003
What is Prognostication?
Foreseeing
(determining)
Foretelling
(relaying)
Slide used with permission, courtesy of Lindy Landzaat, DO
Why Prognosticate?
• Hospice eligibility
• Goals of care
• Advanced care planning (financial, ADL)
• Resource allocation
• Clinical decision-making
Alrawi YA, et al. Q J Med 2013; 106:51-57
Chan TC, et al. Geriatr Gerontol Int 2012; 12:555-562
Widera E, et al. JAMA 2011; 305(7):698-706.
Yourman LC, et al. JAMA 2012; 307(2):182-192
Ways to Prognosticate
Clinical Judgment
Slide used with permission, courtesy of Eric Widera, MD
Shortcomings of Clinical Predictions
• Tend to overestimate patient survival by a
factor of between 3 and 5.
• Tend to be more accurate for very shortterm prognosis than long-term prognosis.
• Influenced by relationships
Christakis NA and Lamont EB. BMJ. 2000 Feb 19;320(7233):469-72
Slide used with permission, courtesy of Eric Widera, MD
Ways to Prognosticate
Clinical Judgment
Life Tables
Slide used with permission, courtesy of Eric Widera, MD
Great Variation in Life Expectancy
for People of Similar Ages
Life Expectancy for Women
25
Top 25th Percentile
50th Percentile
Lowest 25th Percentile
20
Years
15
10
5
0
70
75
80
85
90
Age (years)
Walter LC. JAMA 2001;285:2750-56
Slide used with permission, courtesy of Eric Widera, MD
Use Functional Status
Life Expectancy (years)
Age
Independent
Mobility
disabled
ADL
disabled
70
16.7
15.7
11.5
75
13.2
12
8.2
80
10.3
9
6
85
8
6.9
4.6
Keeler et al. J Gerontol A Biol Sci Med Sci. 2010
Slide used with permission, courtesy of Eric Widera, MD
Prognostication is more
accurate if you combine
clinical judgment with
life tables, functional
status and comorbid
conditions
Walter LC. JAMA 2001;285:2750-56
Christakis & Iwashyna, Arch Intern Med 1998
Keeler et al. J Gerontol A Biol Sci Med 2010
McGinn, JAMA 2000
Ways to Prognosticate
Clinical Judgment
Life Tables
Prognostic Indices
Slide used with permission, courtesy of Eric Widera, MD
Prognostic Indices
Physicians can use prognostic
indices to lend confidence to their
judgments about prognosis
National survey of 697 physicians: 57% felt
inadequately trained in prognostication
Christakis & Iwashyna, Arch Intern Med 1998
Slide used with permission, courtesy of Eric Widera, MD
• Identified 16 validated non-disease
specific prognostic indices for older adults
• 6 for community dwelling adults
• 2 for nursing home
• 8 for hospitalized patients
• Results used to form ePrognosis.ucsf.edu
Yourman LC, et al. JAMA 2012; 307(2):182-192
Used with permission, courtesy of Eric Widera, MD
• Identified 8 risk factors
• ROC 0.76
• Compared to Flacker long-stay NH index (ROC 0.73)
Chan TC, et al. Geriatr Gerontol Int 2012; 12:555-562
?
Created By: Medical College of Wisconsin. Available at POGOe.org, Assessed 2/16/14
Medicare Hospice Criteria
for Dementia
• Stage 7 or beyond on the Functional
Assessment Staging Scale (FAST)
• One of the following within the past 12 mo:
o
o
o
o
o
o
Aspiration pneumonia
Pyelonephritis or other upper UTI
Septicemia
Decubitus ulcers, multiple, stage 3-4
Fever, recurrent after antibiotics
Inability to maintain sufficient fluid and calorie intake with 10%
weight loss during the previous six months or serum albumin < 2.5
• C-statistic for ADEPT 0.62-0.72
• C-statistic for Medicare hospice eligibility 0.55
Mitchell, SL, et al. JAMA 2010; 304(17):1925-1935
Prognostication:
limitations
• Medicare hospice criteria are guidelines, not hard
and fast rules
• Indices may have limited clinical utility outside of
the population in which they were created
• Indices based on MDS 2.0 or ICD-9 codes no longer
useful as data management changes
• Questionable discriminatory ability of indices
Yourman LC, et al. JAMA 2012; 307(2):182-192
Used with Permission
Acknowledgements
• A special thank you to those who shared articles,
web resources, slides and support
o
o
o
o
Amy Corcoran, MD, CMD – U of Pennsylvania
Eric Widera, MD – U of California San Francisco
Lindy Lanzaat, DO – U of Kansas Medical Center
Paul Tatum, MD – U of Missouri