Hospice is comprehensive care
for the dying. The focus of hospice care is comfort, and thus having
hospice care can help ensure a peaceful rather than a painful death.
Hospice is covered by Medicare Part A if the beneficiary has a life expectancy
of six months or less. If the terminally ill beneficiary elects the
hospice benefit, he waives curative treatment for his terminal illness, but
can continue to receive curative treatment for other illnesses.
Hospice was originally
envisioned to be a non-institutional benefit. That is, it was expected
that beneficiaries who elected the benefit would receive hospice care within
their homes. However, it is possible to receive Medicare covered hospice
care while residing in a nursing home. And since one out of every three
people admitted to a nursing home is expected to die within one year, one would
expect that a significant amount of beneficiaries living in nursing homes would
be receiving hospice care. Yet currently, fewer than 15% of nursing
home residents receive hospice care.
Contract for Hospice Care:
Mrs. Haviland recently fell and
broke her hip. Consequently, she was hospitalized for three days and
then entered a nursing home to participate in physical therapy five days a week.
While she was receiving the physical therapy, Mrs. Haviland’s physician
diagnosed her with terminal liver cancer and certified that she had a life
expectancy of six months or less. Technically, Mrs. Haviland
qualifies for Medicare hospice coverage. Realistically, however, there are
several hurdles which may make it impossible for her to access hospice care.
The first hurdle is a billing
quagmire. In order to receive Medicare covered hospice care, Mrs. Haviland
must reside in a nursing home that has a contract with a hospice agency for the
provision of hospice care. At this time, there is no legal requirement
that nursing homes contract with hospice providers. So even though Mrs.
Haviland is dying of liver cancer, if her nursing home does not have a contract
with a hospice agency for the provision of hospice care, she will not be able to
receive Medicare covered hospice care.
Currently there are many
reasons why Mrs. Haviland’s nursing home may be reluctant to contract with a
hospice provider for hospice care. To begin with, the administrators of
the nursing home may believe that the staff at the nursing home has the needed
expertise to provide end-of life care. In other words, they may view
hospice care as a duplicative service. Secondly nursing homes are heavily
regulated. The administrators of the nursing home may believe that the
hospice philosophy of care, that is, a focus on caring rather than cure,
violates nursing home regulations. Consequently, the nursing home
administrators may choose not to contract with a hospice agency for the
provision of hospice care.
Room and Board:
There is another significant
barrier to receiving hospice care while residing in a nursing home. This
is the fact that the Medicare hospice benefit does not pay for room and board.
For instance, if Mr. Aubois is receiving daily skilled nursing care in the
nursing home for his terminal heart condition, regular Medicare Part A pays for
both his medical care and his room and board. However, if he were to elect
the Medicare hospice benefit, Medicare would pay for hospice care, but not for
his room and board.
This is significant because
room and board in a nursing home can cost over $8,000 per month. So,
unless Mr. Aubois has alternative insurance, such as Medicaid, that would pay
for his room and board, if he elects the Medicare hospice benefit, Mr. Aubois
will also be electing an $8,000 monthly bill for room and board.
On the other hand, Mrs.
Haviland qualifies for both Medicare covered hospice care and Medicare
covered room and board. This is due to the fact that she has two
diagnoses: the broken hip which qualifies her for Medicare skilled nursing
facility coverage, and terminal liver cancer which qualifies her for hospice
coverage. As long as Mrs. Haviland continues to receive physical therapy
five days per week, Medicare will cover her physical therapy, her hospice care,
and her room and board. Unfortunately, once her physical therapy ends,
although she will continue to be eligible for Medicare covered hospice care,
Medicare will no longer cover Mrs. Haviland’s room and board.
General Inpatient Hospice
Care or Respite Care:
Alternatively, room and board
in a nursing home can be covered under the Medicare hospice benefit if the
beneficiary requires hospice general inpatient care or hospice respite care.
For example, if Mrs. Bailey was receiving hospice care at home, but her care
became unmanageable in the home, she would qualify for the hospice general
inpatient benefit. That is, she would be transferred to an inpatient unit
(either in a hospital or in a nursing home) where her care could be managed.
While Mrs. Bailey was receiving her hospice care in the inpatient unit, Medicare
would pay for her room and board.
Hospice respite care differs
from general inpatient hospice care in that coverage is triggered not by the
beneficiary’s medical need, but by the needs of the beneficiary’s family.
Mr. Cassidy, for instance, was receiving Medicare covered hospice care in his
home. His primary caregiver was his wife, Mrs. Cassidy. Due to the
demands of caring for a dying person, Mrs. Cassidy has not been sleeping well.
Of course, it is not healthy for a person to go without sleep. Under the
Medicare hospice benefit (so that she can catch up on her sleep), Mrs. Cassidy
can be spelled from the demands of caring for her terminally ill husband.
This spell is called respite care. During respite care, Mr. Cassidy will
be treated in an inpatient unit (either a hospital or a nursing home), so that
Mrs. Cassidy can catch up on her sleep. During respite care, Medicare
will pay for both Mr. Cassidy’s hospice care and for his room and board.
What Needs to Change:
Ideally, Medicare should cover
room and board for beneficiaries who reside in nursing homes and have elected
the hospice benefit. This change requires Congressional action as it can
only happen if there is a change in the Medicare statute. In the mean
time, as a condition of participation in the Medicare program, the Centers for
Medicare and Medicaid Services (CMS ) should require that nursing homes
establish contracts with hospice providers for the provision of hospice care.
Or, at the very least, as a condition of participation, CMS should require that
nursing homes inform potential residents about the Medicare hospice benefit and
whether or not the nursing home has a contract with a hospice program.
CMS should also encourage
nursing homes to contract with hospice agencies for the provision of hospice
care. To this end, through education and explicit statements of policy,
CMS should ensure: that nursing home providers understand that hospice
care is a distinct benefit from nursing home care; that hospice care will
enhance the quality of care provided within the nursing home; and that the
palliative focus of hospice care does not violate nursing home regulations.
Terminally ill Medicare
beneficiaries can receive Medicare covered hospice care while they reside in a
nursing home. However, there are several hurdles to accessing this care.
These include the requirement that the nursing home have a contract with a
hospice provider for the provision of hospice care and the fact that the
Medicare hospice benefit does not generally include financial coverage for room
and board. Given the importance of ensuring that Medicare beneficiaries do
not die in pain, Congress and CMS should change the law and policy such that
those living in nursing homes can more easily access hospice care.