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Like most eldercare advisors I
tend to recommend that families consider Hospice
care when a patient seems to have exhausted all
the available medical options. As a rule we
encourage this option as early as possible,
because the support and care offered by most
Hospice agencies is so beneficial to the patient
and their families. Rather than wait until the
end is imminent, we hope that patients and
families will opt for Hospice as soon as they
are eligible.
In 1998 Hospice regulations were loosened to
permit Medicare beneficiaries to receive care
for longer than six months if, in the best
judgment of their physician, their life
expectancy remained at six months or less. This
meant that Hospice patients could be
"recertified" for an unlimited number of 6 month
periods, as long as their life expectancy
remained 6 months or less. Many patients have
received Hospice care for several "certification
periods" under this new rule.
However, things may be changing again, and it is
important to know how Hospice agencies are paid
for their work so you can understand and
hopefully work around any Hospice roadblocks you
may encounter in the future.
Like all medical providers, Hospice agencies
must make a profit from providing care to
terminally ill patients or they will soon no
longer be able to provide care. Even "nonprofit"
agencies must make enough to cover their
expenses.
The way Hospice agencies are paid for providing
care has a lot to do with whether you will be
able to receive care when you and your doctor
think it's time.
Medicare has capped the amount that they will
pay an agency for providing Hospice care to any
single patient. This year that cap is $21,410
for the fiscal year ending October 31, 2007.
This cap is not a cap on the amount an
individual patient may use. Instead, it is a
per-patient cap on the amount the Hospice
provider will be paid per patient. If the
Hospice provider ends the year having received
more than $21,410 per patient, they must return
any overpayment to Medicare.
To put it simply, for every patient who lives
longer than six months with Hospice care, that
Hospice must have several patients who lived
considerably less than 6 months, so that the
average cost for all their patients remains
under $21,410 for the year.
In the beginning, Hospice cared primarily for
cancer patients. It was fairly easy to predict
how long any individual patient would live
because most cancers are predictable. However,
in recent years Hospice providers have been
caring for more patients who have unpredictable
illnesses, such as dementia or heart disease.
These patients often outlive their initial six
months' prognosis. As a result, the amount that
these agencies have had to send back to Medicare
is in the millions.
What this means for you is that from now on you
may find it harder to find a Hospice agency that
is willing to admit your loved one unless he or
she has a well-defined illness, such as cancer.
While Medicare still says that a beneficiary is
Hospice-eligible if he or she has a "life
expectancy of 6 months or less if the terminal
illness runs its course," for those with an
illness that is less predictable, you may find
that you can't get Hospice care until your loved
one is "actively dying."
If you and your doctor have decided together
that it is time to turn to Hospice care, you may
find that you have to "shop" several Hospice
agencies to find one that will admit your loved
one. Much will depend on the "patient census" of
the Hospices you contact, and how confident they
are that admitting your loved one will not send
the agency too far over the "cap." Each Hospice
will have a different patient population. One
may have several patients who have been with
them longer than six months. They will
understandably be cautious about adding more
patients who may live longer than six months.
Others may have fewer patients who have been
with them more than six months. These agencies
will be more willing to "take a chance."
Bless all Hospice agencies. They are being
forced to walk a financial tightrope they didn't
anticipate when they began providing care. Most
are fine people who have a dedication to their
mission that is hard to comprehend. They are
devastated when they have to turn patients down.
But if they don't, they will soon be out of
business.
So don't give up if one agency tells you they
can't admit your loved one. Keep trying.
Eventually you should find a willing and able
agency.
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