Posts Tagged ‘hospice’

CMS: Hospice Patients CAN Appeal Their Care Provider’s Decisions

JULY 9, 2012 VOLUME 19 NUMBER 26
Surveys indicate that recipients of Medicare benefits are consistently pleased with the care they receive. Hospice patients (and their families) often express even higher levels of satisfaction — even though the patient so often dies. But not all hospice patients are pleased with the care they receive, and some will inevitably want to challenge the care providers’ decisions. How do they do that? It can be difficult to figure out.

Harold Block (not his real name) provides a case in point. When his wife was diagnosed as terminally ill, Mr. and Mrs. Block decided to enroll her in a hospice program available through Medicare. All of her care was provided by the hospice provider, and Medicare paid virtually all of the costs of care.

Mrs. Block soon found that the pain medications she was receiving were simply not adequate. Her attending physician agreed, and prescribed Actiq, a powerful drug intended to treat “breakthrough pain.” Mr. Block immediately filled the prescription, paying out of his own pocket. In the last month of his wife’s life he paid $5,940 for the painkiller.

A few months after his wife’s death Mr. Block submitted the receipts for her medications to the hospice organization for payment. They declined to reimburse him. He wrote to the hospice group again, noting that the drug had been prescribed by her attending physician, that it had been part of her care plan (which had been signed by her hospice team, as well), and that he intended to appeal the denial of coverage. The hospice organization told him he should address his appeal to National Government Services, a “fiscal intermediary” that handles Medicare provider’s claims.

Mr. Block wrote to the fiscal intermediary. He received a response telling him that only the legal representative of his wife’s estate could pursue the claim. He sent back documents showing he had been appointed as personal representative of her estate. He received another letter telling him he would have to prove that he had legal authority. He sent another copy of the legal documents. Frustrated, he hired an attorney, who wrote to the Centers for Medicare and Medicaid Services (CMS), telling them that Mr. Block wanted to appeal the denial of coverage for his wife’s medication.

CMS responded to the attorney saying that only the original hospice provider could appeal the denial. Since he was seeking to appeal a denial of coverage BY the same hospice provider, Mr. Block and his attorney decided he would need to sue CMS.

Eighteen months after his wife’s death, and still not having gotten any substantive answer to his request for reimbursement, Mr. Block filed a lawsuit against CMS in California’s federal court. His allegation: CMS had to provide an appeal mechanism for dissatisfied hospice patients under Medicare law and federal Constitutional principles. CMS’s response: there IS an appeal process, just not the one that Mr. Block had been told about. The trial judge, based on CMS’s representations about an available appeal process, dismissed his lawsuit.

The Ninth Circuit Court of Appeals upheld the dismissal, finding that there is an appeal process for unhappy hospice patients — though no one in the Medicare or hospice system seemed to be able to tell Mr. Block where he should file his appeal or how it would work. The first step in the appeal process, wrote the appellate court, would be for Mr. Block to request the hospice provider to reconsider its denial (forget that the hospice provider already told Mr. Block — incorrectly — that he should appeal to the fiscal intermediary). Next step: ask for reconsideration of the redetermination (no, we’re not kidding here). Next step after that: appeal to a Medicare Administrative Law Judge, then to the Medicare Appeals Council for review and then, if none of those steps has worked, to court for formal judicial review.

“We understand [Mr. Block’s] frustration, having been misinformed by CMS and forced to hire an attorney and bring suit to be properly informed of his right to appeal,” wrote the appellate court. Notwithstanding that frustration, wrote the judges, Mr. Block “already has the only relief he seeks — he and other hospice beneficiaries may utilize the [CMS] procedures to appeal a hospice provider’s refusal to provide a drug or service. We expect that the Secretary [of CMS] will take action to ensure that her agencies are properly informed in the future.”Back v. Sebelius, July 5, 2012.

For our part, we look forward to seeing clarification of Medicare hospice beneficiaries’ right to appeal unfavorable decisions. With that appellate process clarified, satisfaction levels can only improve even further. We also hope that Mr. Block gets his $5,940 back sometime soon — he’s waited four years for it so far. To that end, CMS has agreed not to assert that Mr. Block waited too long to file his appeal — which would be the case if he had just waited for those four years to pursue his claim.

Nursing Home Costs, Hospital Admissions and Hospice Use

APRIL 29, 1996 VOLUME 3, NUMBER 44

This week, Elder Law Issues reports a number of trends, statistics and individual items which we have been collecting for weeks. None warrants its own Issues article, and yet each is interesting enough to justify mention.

Nursing Home Costs

Figures have been released for the cost of nursing home (and other health care) in 1993. More recent statistics are not yet available.

Nursing home expenses totaled $69.6 billion in 1993. Money for nursing home care came from both private and government sources. Among the latter, Medicaid (including Arizona’s ALTCS program) paid 51.7%, Medicare 6.5% and all other government sources (including the Veteran’s Administration) 4.4%. The remaining (private) sources of nursing home funds consisted mostly of insurance payments (2.5% of the total) and out-of-pocket payments by private individuals, which accounted for 33% of the costs.

These figures reflect an increase in the share paid by private insurance, though it remains a small part of the nursing home financing picture. The government’s share of nursing home expenses (as well as all other medical expenses) continues to increase. Although nursing home figures for 1994 are not yet available, total medical expenses increased by about $50 billion, or just under 6%. Of that increase, government sources accounted for $33 billion, though remaining slightly smaller than the share paid by individuals and insurance companies.

While Medicare pays a small fraction of nursing home costs, the picture is quite different for home care services. Medicare accounted for 38.8% of such payments in 1993, while Medicaid paid only 15.5% and other government programs picked up .5% of home care costs. Private insurance paid another 12.2% of the cost of home care, and patients’ out-of-pocket expenses totaled 20.8%.

Hospital Admissions

According to the American Hospital Association, hospital use by elderly patients increased in the first quarter of last year. Quarterly statistics show that utilization is highest in the first quarter of each year, but that the increase in 1995 over 1994 utilization was about 4%. Nonetheless, the total number of hospital days actually dropped; the average length of stay for elderly patients fell from 8 days to 7.3 days during that time period.

Critics of the efforts to reduce hospital costs in recent years frequently refer to current discharge practices as getting patients out of the hospital “sicker and quicker.” Utilization statistics clearly support the “quicker” part of the formulation, in any event. One result of this trend: defying recent trends, medical costs increased less than the consumer price index.

Hospice Underutilized

According to the National Hospice Organization, hospice services continue to be implemented in a small minority of cases where they would be appropriate. The Organization estimates that in 1994 fewer than 15% of eligible Medicare patients actually enrolled in hospice.

Many Medicare recipients are unaware of the terms of the hospice benefit, which is considerably more generous than other Medicare programs. In most circumstances, hospice enrollees pay no co-payments or deductibles, and have all prescription drugs provided. By contrast, Medicare beneficiaries (except those enrolled in Medicare HMOs) usually pay for all their own medications, and 20% of the approved cost of most other outpatient medical treatment.

Because of the perceived underutilization of hospice programs, federal law now requires hospitals and nursing homes to specifically consider hospice benefits at the time of discharge. The new law became effective in November, 1995.

HMOs and Hospice

MAY 8, 1995 VOLUME 2, NUMBER 44

In recent years HMOs have come to dominate the Medicare field in Arizona. Although marketing sometimes suggests that Medicare recipients “give up” their Medicare benefits to join an HMO, it is important for consumers to realize that the HMO is simply an alternative method of delivering Medicare services.

“Medicare HMOs” (those HMOs providing coverage to Medicare recipients under special arrangements with the federal government) are required to provide the same range of services available to traditional Medicare participants. Of particular significance to many seniors is the requirement that Medicare HMOs provide full hospice benefits.

Medicare Hospice Benefit

Traditional Medicare does not pay for prescription drugs at all and has limited benefits for counseling. In addition, Medicare patients must pay an annual deductible and (in most cases) 20% of the cost of their care. For those enrolled in traditional “fee for service” Medicare plans, these limitations do not apply to hospice benefits.

For the past decade, Medicare has provided full coverage for hospice patients, including prescription drugs, supportive care and counseling (including grief counseling for family members). There is no deductible or copayment for these services. Eligibility does require a diagnosis of terminal illness, with less than approximately six months to live and a desire to “forego curative treatment options.”

The HMO Connection

For those patients who have elected to join a Medicare HMO, the rules may seem to have changed. Since prescription medications may now be partially covered (many plans provide coverage with a modest per-prescription copayment) and the HMO focuses on preventive care, the consumer may be misled into believing that Hospice benefits are treated differently as well.

In fact, Medicare requires that participating HMOs provide full Hospice benefits under the same terms as traditional Medicare coverage. Most HMOs contract with one of the private or non-profit Hospice organizations to provide the required services, and the patient will perceive the transition as having been moved “back on to” Medicare.

Medicare HMOs are discouraged from selecting only the healthiest Medicare beneficiaries. Consequently, they are required to accept nearly all applicants; one of the two major exceptions to this principle is that those already receiving Hospice benefits may not transfer to an HMO. Since the benefits are the same for Hospice patients, however, that should not present any problems for consumers.

Arizona White House Conference on Aging


The Arizona White House Conference on Aging held in Phoenix last month dealt with issues facing the full White House Conference on Aging when it meets in May. Arizona’s delegation dealt with several issues expected to dominate the national aging agenda.

Long Term Care

Everyone knows that the proportion of elderly citizens is expected to grow dramatically in the next two decades. What many do not appreciate is that the greatest growth is projected for the “old old”; those over age 85. Currently one-quarter of all women (but only one-seventh of men) over age 85 live in nursing homes. Those who turn 65 in any given year have about a 40% chance of spending some portion of the rest of their lives in a nursing home. About 10% of those will spend five or more years there.

Another tremendous segment of the population requires long-term care, but receives care at home. About 70% of all long-term care of the elderly is provided solely by family and friends, without institutionalization.

For those who can be cared for at home, the cost of assistance may be prohibitive. Simply bringing an aide into the home three times a week for meal preparation and light housekeeping can easily cost in the range of about $600 per month. Since about 20% of Arizona’s elderly live at or near the federal poverty level, even such small assistance may be unaffordable.

For those placed in nursing homes in Arizona, the cost of care will typically vary from $30,000 to $40,000 per year. Many seniors expect Medicare to pay some portion of that cost; in fact, Medicare pays only about 3% of the total nursing home bill in this country. Private long-term care insurance (still a relative rarity) and Veteran’s benefits account for another percent or two each; the remaining portion of long-term care costs are paid roughly equally by Medicaid and patient’s private savings and income.

Although nursing homes care for less than one-fifth of those requiring long-term care, they are responsible for more than half of the cost of care. Seniors are reluctant to enter the nursing home, and much prefer to be cared for (and die) in their homes.

Cost effective alternatives to institutionalization exist, especially in urban areas. Adult day care, respite care, hospice and assisted housing programs can keep many nursing home candidates in less expensive settings and more comfortable. Unfortunately, such programs are too rare and are seldom funded by public dollars. Paradoxically, it becomes less expensive for most patients to move into the nursing home and qualify for Medicaid (ALTCS in Arizona) than to secure care at home or in a more home-like setting.

Hospice and Medicare


When a terminally ill patient needs care at the end of life, hospice programs are often the best choice available. Family members may gain as much (or more) from the hospice experience as that patient himself. Most providers know the value of hospice, but the availability of hospice programs, the variety of programs and the possibilities for Medicare funding are widely unknown or misunderstood.

A number of common myths about hospice care prevail in the medical and nursing community. With thanks to Dasa Colsman of Hospice Family Care, Inc., a few of those myths can be exploded.

Medicare does not limit its coverage to six months of hospice care. Medicare coverage for hospice care is not available until the prognosis is for less than six months of life. Unfortunately, many practitioners misunderstand this benefit limitation and delay referral to hospice programs until the last hours or days of life.

Hospice provides a great deal more than traditional nursing services. Although nurses are trained to deal with dying patients, the special training and orientation of hospice workers is of great benefit to patients and family members. More importantly, Medicare coverage for hospice patients does not include a co-payment and all prescriptions, disposable and necessary medical equipment is covered. For that matter, so are individual and family counselling, caregiver assistance and grief support. Consequently, terminally ill Medicare patients actually get much more service through the hospice program than traditional nursing services, even when provided in the nursing home.

Hospice services can be delivered in the nursing home. Non-Medicare patients can receive hospice services in the nursing home. Provision of hospice services must be coordinated with the nursing facility.

HMO members can receive hospice care. The Medicare hospice benefit is available to those who subscribe to one of the growing number of Medicare HMO programs. The primary physician remains responsible and directs the medical care component.

Hospice care is appropriate for people who are not suffering from AIDS or cancer.Although those two illnesses are the ones most commonly thought about in relationship to hospice programs (in 1992, 78% of US hospice patients had a diagnosis of cancer), any terminally ill patient, regardless of diagnosis, can be admitted to many hospice programs.

Hospice patients do not have to “give up” on all forms of treatment. Although curative treatment is not provided in hospice programs (since the very nature of the programs is to deal with the inevitability of death in the near future), “palliative” care is provided. Radiation, chemotherapy, intravenous administration of medications and other therapies may sometimes be aimed at relieving pain or making the process easier, and many hospice programs will permit continued administration of such therapies.

Hospice services can be provided in the home on a part-time basis. Not all hospice programs are based in institutions, nor do they all require 24-hour attendants. Different programs are intended to deal with different patient needs.

According to statistics provided by Hospice Family Care, Inc., 12,000 Arizonans died from terminal or irreversible illnesses in 1990. Only 4,500 (or about 37%) had hospice care.

Heart Surgery Benefits Elderly

MARCH 21, 1994 VOLUME 1, NUMBER 18

Coronary bypass surgery is increasingly common among the elderly. In fact, many hospitals report that between 10% and 25% of coronary bypass patients are over 80.

Until recently, little research had been conducted into the success rates of heart surgery in older patients. Now, Dr. Paul Stelzer of New York’s Lenox Hill Hospital has reported on a study following 168 elderly patients after heart surgery. Dr. Stelzer’s results indicate that such patients do well, provided that they were in reasonably good health before the surgery.

According to Dr. Stelzer’s report, nearly 6% of patients died immediately after surgery, which is double the death rate in younger patients. The risk of other complications, including stroke, sepsis and kidney failure, was also roughly twice the similar risk in younger patients. Still, the risk of death or serious complications was low enough that the benefits of surgery outweighed those risks.

About his elderly subjects, Dr. Stelzer says “they deserve a chance, unless they’ve got some big strikes against them.” He indicates that elderly patients with weak left ventricles or a history of strokes or kidney disease may not be good candidates for the surgery. He also says the elderly heart patient must have a strong will to survive.

Living Wills Cut Patient Care Costs

Another recently released study shows what many already knew intuitively. Costs of caring for patients during the end-of-life period are significantly lower when the patient has executed an advance directive.

According to the study, published in the March issue of Archives of Internal Medicine, Medicare patients with advance directives cost a little more than one-third of the amount spent on patients without directives during the end-of-life treatment period. For the 342 patients without directives studied, the average cost of the final hospital stay was $95,305. For the 132 patients with directives, the comparable figure was $30,478.

The study’s director, Dr. Christopher V. Chambers, of Thomas Jefferson University in Philadelphia, says that the study “shows that respecting a patient’s right to choose the kind of medical care received at the end of life also results in a tremendous benefit to society by limiting resources spent on futile and often unwanted attempts to prolong life.” The study also inadvertently reveals how few patients have executed advance directives.

Q & A

Q: In an answer you gave two weeks ago about the care of a terminally ill woman, you completely failed to mention the support and services available from an accredited hospice program. What’s wrong with you, anyway?

(Ed. note–OK, I changed the question a little bit)

A: You are right. The earlier question did not really address the kind of care to be administered to the patient, but asked about the need to fully inform the patient of her terminal condition. I should have mentioned that, in addition to being expert at dealing with end-of-life care, hospice providers are also experts at the social, psychological and emotional issues associated with patient care and family dynamics. A consultation with a hospice provider might have been the best possible suggestion.

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