Management strategies for palliative care: promoting quality, growth and opportunity

Over 20 years ago, hospice in the United States evolved to provide end-of-life care for terminally ill patients. However, three major barriers exist, which limit access to hospice care. The first two, cultural and regulatory barriers, are not under the direct control of hospices, although programs can be adapted to minimize their influence. The third, management focus, is controlled by hospice programs and has the greatest influence on access to care and quality of care. Under the influence of the Medicare Hospice Benefit and the peer pressure of managed care, many hospice programs use reimbursability as at least one criterion for determination of coverage of services. The fear is that limited reimbursement will cause some services and therapies to bring the programs to financial ruin. This case study shows the outcome of changing management focus away from restrictive policies about therapies and patient selection toward management of productivity and working capital. Some programs have contributed to growth and stability; the revenue thus produced has supported the new innovations. San Diego Hospice is now growing more than 30 percent per year in spite of competition and a fairly flat death rate in the community. This growth is attributed to finding and meeting unmet needs and making all decisions based on the right thing to do. Every staff member understands and supports the mission. The many programs within the agency contribute to fulfillment of the goal to transform end-of-life care. They are presented here as an example of what can be done with mission-based management.     

A Review of Barriers to Utilization of the Medicare Hospice Benefits in Urban Populations and Strategies for Enhanced Access

Disparities in access to health care extend to end-of-life care. Lack of access to hospice mirrors lack of access to health maintenance and primary care. Patients who are served by hospice nationally are disproportionately white and likely to reside in economically stable communities. In many urban low-income communities, less than 5% of decedents receive hospice care in the last 6 months of life. This review focuses on barriers to palliative care and hospice in urban, predominantly low-income communities, including cultural and reimbursement factors and the paucity of hospice providers, outreach projects, and in-patient hospice beds in urban communities. This review will also address some strategies that are being implemented by hospices locally and nationally to overcome demographic barriers to hospice care.     

Cost differences between hospice and nonhospice care. A comparison of insurer payments and provider charges.

Although it has been postulated that hospice care savings are "biased" when costs are measured in terms of insurer payments instead of provider charges, this claim has not been documented by research. This article examines cost differences between hospice and nonhospice care, first, by analyzing Medicare Part A payments and, second, by studying provider charges for services rendered to a population of 24 cancer patients during their last 24 weeks of life. The exploratory results of the study showed that although the cost savings derived from analyzing provider charges were about double those based on Medicare Part A payments, both approaches to the measurement of cost strongly indicated that hospice home care was less costly than nonhospice care. Further analysis showed that variations in the rates of Medicare reimbursement accounted for 22 to 42% of the differences in the derived cost savings between the two approaches to measuring cost, and that payments to hospitals played a major role in determining this outcome.     

Nursing home case-mix reimbursement in Mississippi and South Dakota

OBJECTIVE: To evaluate the effects of nursing home case-mix reimbursement on facility case mix and costs in Mississippi and South Dakota. DATA SOURCES: Secondary data from resident assessments and Medicaid cost reports from 154 Mississippi and 107 South Dakota nursing facilities in 1992 and 1994, before and after implementation of new case-mix reimbursement systems. STUDY DESIGN: The study relied on a two-wave panel design to examine case mix (resident acuity) and direct care costs in 1-year periods before and after implementation of a nursing home case-mix reimbursement system. Cross-lagged regression models were used to assess change in case mix and costs between periods while taking into account facility characteristics. DATA COLLECTION: Facility-level measures were constructed from Medicaid cost reports and Minimum Data Set-Plus assessment records supplied by each state. Resident case mix was based on the RUG-III classification system. PRINCIPAL FINDINGS: Facility case-mix scores and direct care costs increased significantly between periods in both states. Changes in facility costs and case mix were significantly related in a positive direction. Medicare utilization and the rate of hospitalizations from the nursing facility also increased significantly between periods, particularly in Mississippi. CONCLUSIONS: The case-mix reimbursement systems appeared to achieve their intended goals: improved access for heavy-care residents and increased direct care expenditures in facilities with higher acuity residents. However, increases in Medicare utilization may have influenced facility case mix or costs, and some facilities may have been unprepared to care for higher acuity residents, as indicated by increased rates of hospitalization.     

Developing and financing a palliative care program

Although hospice care to assist the dying is widely available, palliative care, which focuses on living with chronic and life threatening illness and preparing the living for dying, is poorly understood. Only recently, palliative care has been mandated by the Joint Commission on Accreditation of Healthcare Organizations as a necessary intervention for facilities. Defining a palliative care model for the community hospital emphasizes total care for the patient beyond the traditional medical model. No specific Medicare reimbursement exists for palliative care in hospitals, and hospital administrators are generally not supportive of programs where no reimbursement exists. Developing a model palliative care program using a cost aversion financial model to quantify benefits of a palliative care programs is one strategy to address the reimbursement shortcomings.     

The U.S. hospice movement: issues in development.

A grass-roots hospice care movement is underway in the United States modeled after recently popularized British hospice programs. Hospice care is intended to help the terminally ill maintain a personally acceptable quality of life until death. Attention should be given to ensuring the future viability of this service option by allowing for experimentation with and adaptation of existing models, and by integrating it with the overall health care system. Issues to be considered in integrating hospice care include utilization of existing resources, regional planning, standards and licensure, and reimbursement opportunities. Although hospice care may not have an immediate cost savings impact on the health care system, it could develop this capacity in the future. Such impact would not only assure a stable financial base for hospice care but would also affect bed use generally. Continuing dialogue among providers, consumers, and policy makers of various backgrounds is necessary to the effective and appropriate development of hospice care in the U.S.     

Medicare physician payment changes: impact on physicians and beneficiaries

The Balanced Budget Act (BBA) of 1997 generally reduced Medicare payments for surgical services while increasing them for other services. Concern about implications of these fee reductions prompted the Medicare Payment Advisory Commission to sponsor a national survey of physicians to learn their views on Medicare payment and whether access to care has changed for Medicare beneficiaries. Results suggest that beneficiaries' access to care has not declined. While physicians are concerned about Medicare reimbursement, they are more concerned about reimbursement from managed care plans and Medicaid. Continued monitoring will be important to detect any emerging access problems accompanying upcoming payment reductions.     

Hospice for aged persons without cancer: the experience of the Hampshire County (MA) hospice

Hospice is an option for patients with terminal illness of all types. The advent of the Medicare hospice benefit has led to a rise in numbers of hospice programs as well as hospice expenditure. Terminal care provided through hospice has a demonstrable cost advantage over conventional terminal care. This difference may dissipate as Medicare hospice expenditure continues to rise. An individual hospice program can define its mission within broad guidelines. A program electing to serve all terminally ill patients regardless of diagnosis can occasionally expect to be cast in the role of long term care-provider when six-month survival is exceeded. Precision in prediction of six-month survival would benefit patients and remove one major obstacle to participation by many primary care physicians. Prognostic techniques are being developed that, thus far, have proven no better than physician judgement in assigning risk or predicting survival. Hospice may provide a setting for clinical research of prognostication. The interdisciplinary team can facilitate hospice care and provide support to individual team members. Care of terminally ill non-cancer patients may require added human resources and alteration of team structure to cope with increased service needs and lengths of stay which may be likely to exceed those of cancer patients.     

Trends and patterns in place of death for Medicare enrollees

Two changes in the Medicare program in 1983 may have affected where aged persons die--the change from retrospective hospital reimbursement to the prospective payment system and passage of the Medicare hospice benefit. Patterns and trends in where people die--hospitals, other institutions such as nursing homes, decedents' homes, and other places--for persons 65 years of age or over from 1980 through 1986 are examined. The proportion of deaths in hospitals declined somewhat after implementation of prospective payment. The hospice benefit may have caused the shift among cancer patients away from hospital deaths toward deaths at home.     

Providing hospice care in rural areas: challenges and strategies

Hospices in rural settings face challenges in the provision of hospice care as a result of their location and the size of their service area population. To ascertain the challenges that hospices face in serving rural communities, researchers conducted in-depth case studies of four different models of hospice care in rural areas. The authors describe strategies used by the case study hospices and recommend policies that could increase access to hospice care for rural Medicare beneficiaries and other rural residents. National initiatives to improve end-of-life care need to consider the special challenges faced by rural hospices.     

The effects of hospice coverage on Medicare expenditures.

This article reports on the findings of a study of the effects of the hospice program on Medicare Part A expenditures during the first three years of the program. The analysis compared treatment costs between hospice beneficiaries and nonbenefit patients with diagnosis of malignant cancer during their last seven months of life. It was estimated that during the first three years of the hospice program, Medicare saved $1.26 for every dollar spent on Part A expenditures. While the methodology included use of data from Medicare claims to adjust for confounding factors, including self-selection bias, our estimated savings might still have been overstated due to persistent selection effects. The extent of savings also varied according to the hospice's organization. Freestanding hospices, in contrast to those affiliated with either a hospital, nursing home, or home health agency, achieved the greatest savings by utilizing home care more extensively. However, we note that payment rates are increasing and the limits on the benefit period are being lifted, making it possible that the savings related to the hospice program found in this study will not continue. Of greater importance may be the long-term access and quality effects engendered by the benefit's preference for home care.     

The primary care clinical nurse specialist. Director of a hospice program?

In summary, hospice is a form of primary health care that developed along with the nurse practitioner-clinical specialist movement in the 1970s as a response to fragmented, impersonal health care. Both movements experienced similar steps of role development and stand today at the beginning of a new era with financial reimbursement possibilities. The role of the primary care clinical nurse specialist as a leader in the distribution of that care is very compatible with the hospice team concept. Utilization of the clinical specialist as director would keep hospice within nursing's field of health care, enhance the caring image of hospice, and maintain the focus on the patient's need in dealing with death and dying.     

The impact of PPS on hospital-sponsored post-acute services: a case study of Delaware Medicare providers

Hospitals were the first providers to experience the change in Medicare reimbursement from a cost basis to the prospective payment system (PPS). In the 1980s, this switch was accomplished through the development of diagnosis-related groups, a unique formula for Medicare reimbursement of inpatient hospital services. During that time, the concern was that, with the anticipated reduced payments to hospitals, adverse impacts on Medicare beneficiaries were likely, including premature release of patients from hospital care resulting in medical complications, increased readmissions, prolonged episodes of recuperation, and preventable mortality. The Balanced Budget Act of 1997 (BBA) mandated the implementation of the PPS for Medicare providers of skilled nursing home care and home health care. This change from cost-based reimbursement to PPS raised concerns that these providers would react as hospitals had done-that is, skilled nursing homes might limit their admission of Medicare patients and home health agencies might cut back on visits. As a result of that, hospitals might be faced with providing care for these post-acute patients without receiving additional reimbursement, and these changes in utilization patterns would be of critical importance to both providers and Medicare beneficiaries. This article examines the decisions that providers made in response to the perceived impact of the BBA. Qualitative data were derived from provider interviews. The article concludes with a discussion of how changes in Medicare reimbursement policy have influenced providers of post-acute care services to alter their level of participation in Medicare and the impact this may have on the general public as well as on Medicare beneficiaries.     

Disparities in End of Life Care for Elderly Lung Cancer Patients

The objective of this study was to examine geographic and race/ethnic disparities in access to end of life care among elderly patients with lung cancer. The study sample consisted of 91,039 Medicare beneficiaries with lung cancer who died in 2008. The key outcome measures included the number of emergency room visits, the number of inpatient admissions and the number of intensive care unit (ICU) days in the last 90 days of life, hospice care ever used and hospice enrollment within the last 3 days of life. Medicare beneficiaries with lung cancer residing in rural, remote rural, and micropolitan areas had more ER visits in the last 90 days of life as compared to urban residents. Urban residents however, had more ICU days in the last 90 days of life and were more likely to have ever used hospice as compared to residents of rural, remote rural and micropolitan counties. Racial minority lung cancer patients had more ICU days, ER visits and inpatient days than non-Hispanic White patients, and also were less likely to have ever used hospice care or be enrolled in hospice in the last 3 days of life. Lung cancer patients with very low socioeconomic status (SES) were less likely to ever use hospice or be enrolled in hospice care in the last 3 days of life, as compared to those who had very high SES. Geographic, racial and socioeconomic disparities in end of life care call for targeted efforts to address access barriers for these groups of patients.     

Equal treatment and unequal benefits: a re-examination of the use of Medicare services by race, 1967-1976.

In the early years of the Medicare program, proportionally more whites than non-whites among the aged used Medicare services. This article examines the use and reimbursement of Medicare services by the aged between 1967 and 1976 to determine if racial differences still exist. To do so, three measures are studied. The first, the number of persons reimbursed for Medicare service per 1,000 enrollees, measures access to Medicare's reimbursement system. The second, reimbursement per person using reimbursed services, measures the amount of reimbursement received after persons exceed Medicare deductibles. The third, reimbursement per enrollee, indicates the combined effect of access and reimbursement and represents a measure of equity for the population at risk. Analysis of the three measures by type of Medicare service found that the disparities in use and reimbursement of services by race decreased considerably between 1967 and 1976. This trend was found both at the national and at the regional level. Overall, the decreases in the disparity measured are note-worthy. By type of service, proportionally more whites than non-whites still receive reimbursement. However, once non-whites exceed deductibles, the reimbursements per person using reimbursed services are generally comparable or higher than reimbursement to whites.     

Characterizing hospice discharge patterns in a nationally representative sample of the elderly, 1993-2000

The aim of this study is to identify the prevalence and correlates of individuals discharged alive from hospice in the Medicare program to determine whether the current hospice benefit matches the needs of dying patients. Using a nationally representative sample of age-eligible Medicare beneficiaries who died from 1993 to 2000, the use of hospice and other Medicare-financed care was analyzed during the last year of life for different groups of hospice users. It was found that 84.5% (n = 1029) of hospice users initiate and use it continuously until death; 15.5% of hospice users are discharged alive, with some later reinitiating hospice. The main difference between continuous hospice users and those discharged alive is the time survived after initial hospice use (those discharged alive live longer). After controlling for survival time, costs per day survived are similar for all groups. This study suggests several motivations for being discharged alive that are worthy of more research.     

Hispanic access to hospice services in a predominantly Hispanic community

Although the largest minority population in the United States, Hispanics are under-represented in hospice at the national level. The study purpose was to document Hispanic access to hospice services in an environment where Hispanics are a majority population. The framework for the study was Aday and Anderson's model for access to medical care. In this framework, access is not defined as availability of services and resources, but whether services are actually used by the people who need them. We completed retrospective chart reviews of 500 Medicare beneficiaries who died in four hospices. Study variables were decedent characteristics and access to hospice and hospice disciplines. Results showed that Hispanics and whites differed on characteristics known to influence access to health services, e.g., preferred language and type of caregiver Although the proportion of Hispanic elders dying in hospice was less than the proportion living in the community, the proportions of Hispanic elders who died in the community or died in their homes were not differentfrom the proportion that died in hospice. When access to hospice disciplines was compared between Hispanic and white decendents, the results showed one difference-more whites than Hispanics had access to volunteer services. Overall, the study showed that Hispanics were not underrepresented in hospice, and they had equal access to hospice disciplines. These findings differ from national data and may be associated with Hispanics being the majority population in the community. To learn how population dominance influences minority access to services, Hispanic access to hospice could be studied in locales with varying proportions of Hispanics in the population.     

The impact of medicare funding on the use of mammography among older women: implications for improving access to screening

BACKGROUND: In 1991, a policy change extended finan cial coverage for biennial mammography to holders of Medicare part B. The impact of this decision on mammography use was examined by comparing mammography use among Medicare-eligible and ineligible women in the years before (1990) and after (1993) the policy change, using National Health Interview Survey (NHIS) data, controlling for socioeconomic indicators and for having a usual source of medical care. METHODS: The Medicare-eligible group consists of 2,419 women ages 65-69 years and women ages 60-64 years who are Medicare-eligible. The Medicare-ineligible group consists of 1,872 women ages 60-64 years. The analysis used logistic regressions and compared women who had undergone mammography in the prior 2 years and controlled for race, ethnicity, socioeconomic status, insurance status, and usual source of care. RESULTS: Medicare reimbursement of mammography appears to have increased the number of Medicare-eligible women who had had a mammogram in the 2 years prior to the survey. However, the analyses suggested that disparities in mammography use due to access to primary care and socioeconomic status persisted after the change in Medicare coverage. Analyses indicated that having additional insurance was the only significant predictor of having a usual source of care among the Medicare population. CONCLUSIONS: This analysis suggests that simply removing financial barriers to mammography for older women (such as the 1998 elimination of a deductible payment for mammograms provided under Medicare) may have limited effectiveness. The strong relationship between having a usual source of care and mammography suggests that disparities in mammography use may reflect inequalities in access to health care in general.     

Medicare revenue in large medical groups

The aged are the heaviest users of physician services. A ageing population and escalation in medical costs have pressured Medicare budgets, which have increased fastest in Part B physician reimbursement. Policy responses include adoption of the Resource Based Relative Value Scale (RBRVS) for physician payment. This paper considers receipt of Medicare revenues by large medical groups and expectations of how groups will fare under RBRVS. In a 73-percent sample of U.S. large group practices, Medicare coverage accounted for one-fourth of clients, Medicare-related revenues for slightly more than one-fourth of revenues, suggesting a slightly higher revenue intensity for Medicare clients, but showing no evidence of truly disproportionate revenues from Medicare users. Medicare shares of revenues are explained by factors related to Medicare clientele and geriatric service provision. Overly-strict Medicare assignment policy may control costs by limiting access to needed care, rather than by limiting overpayments to physicians. Expectations as to how groups will fare under RBRVS are not found to be related to reliance on Medicare, rather to group auspices and ability to contain costs under Medicare payment. The findings are important not only to physician payment under RBRVS but also under health care reform.     

The hospice movement: institutionalizing innovation

The early leaders of the hospice movement shared a number of attitudes with the founders of the alternative institutions of the 1960s and early 1970s: nostalgia for simple, old fashioned ways, dissatisfaction with bureaucratic and authoritarian institutions, faith in the power of nature, a determination to avoid domination by experts, and a desire to improve the quality of personal relationships. However, as hospices have become better established, they gradually have been incorporated into the dominant health care system and have lost their uniqueness. Some have affiliated with hospitals or home health agencies. Even autonomous organizations are subject to pressures for accommodation because they rely on the established order for resources, personnel, and political acceptance. Organizations receiving payment under the new Medicare benefit must adhere to a set of regulations that may distort the movement. Though creation of this benefit may have been facilitated by increased support for hospice ideals, the government views hospices primarily as a way to save money. Paradoxically, as hospices have grown in popularity, the critical force of the movement has been blunted.