In previous posts, we have stressed the importance of telling the ‘story’ of the patient – specifically in the hospice physician certification narrative, and in the determination of relatedness to the patient’s terminal illness. We have visited the regulatory and sub-regulatory guidance that frame how Part D and the Medicare Hospice Benefit interrelate.
I now propose we head back to the hook on which all this hinges – the definition of “terminal illness.” [Note: Please see the comment below from Judi Lund Person from NHPCO for further clarification of the current status of CMS's efforts to define/redefine "terminal illness']. Why? Because this is one of the top priorities of CMS for 2015. of The ensuing definition of “Related Conditions” is equally important. However, that will have to wait until the next post. This is not just a matter of semantics. In the FY2015 Hospice Wage Index Final Rule (79 FR 50451), released on August 22, 2014, and in the section soliciting comments on proposed definitions of these two terms, CMS carefully (and fairly long-windedly), lays out the philosophical, historical, and legal history of the Medicare Hospice Benefit, as we now know it.
To summarize the salient points, or the “Cliff Notes” version if you will...
- The Medicare Hospice Benefit (MHB) was developed to focus on the “total person” at end of life
- Hospices were to “maintain(ing) continuous clinical control over all aspects of care”
- The MHB is “risk-based,” a “fixed sum for all-inclusive end of life care”
- Analyses of payments for Parts A, B, and D services have raised concerns that there is an “unbundling” of hospice services with “cost shifting” to Medicare B and D for services that should be paid for out of the per-diem, capitated hospice payment system for patients at end-of-life
- CMS’s expectation is that hospices “offer and provide comprehensive, virtually all-inclusive care”
See the theme that is emerging? CMS’s argument is that as a vehicle of care delivery, hospice is an integrated model and does not lend itself to compartmentalization; that it is an economic and clinical model that assumes responsibility for the care of the whole person. They reiterate that the 6 months or less prognosis is the key determinant in the definition of “terminally ill” and that “the individual’s whole condition plays a role in that prognosis.” Again, in CMS’s words:
- “All body systems are interrelated”
- In determining prognosis, “assessment should include the ‘total person,’ ‘acute and chronic conditions’ and ‘controlled and uncontrolled conditions’”
- Conditions that are a part of the bundled, covered hospice services should include pre-existing conditions and controlled pain and symptoms
In conclusion, CMS includes the following definition of terminal illness for which they are seeking comments from the stakeholder community, for use in “possible future rulemaking” (take a deep breath):
"Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual’s condition such that there is an unfavorable prognosis and no reasonable expectation of a cure; not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of 6 months or less.”
Do you think there’s anything they left out? Exactly! Terminal illness, by this definition, is a high level, sweeping, and inclusive view of the failing body systems which, when considered in toto, contribute to the limited prognosis. It is a prognostic rather than diagnostic term.
SO… what does this mean for hospices?
- Physicians need to think about all the conditions that are contributing to the 6 months or less prognosis when certifying the patient as terminally ill
- The principal diagnosis should be chosen as the diagnosis most contributory to the limited prognosis
- The physician’s certification narrative must document the choice of principal diagnosis and all conditions considered in determining the terminal prognosis (this not only establishes the patient as terminally ill and therefore clinically eligible for the hospice benefit, it also drives the relatedness decisions, which we’ll cover in the next blog)
- In some cases, the principal diagnosis will be clear (e.g., Stage IV pancreatic cancer). In others, it may not be (e.g., debilitated patient with a rapid trajectory of decline with a history of multiple chronic conditions). The physician needs to choose the diagnosis s/he will most likely list as the primary cause of death on the death certificate
- Hospice physicians are not limited to specific diagnoses that are covered by a published Local Coverage Determination (LCD) guideline; the principal diagnosis might well be without an appropriate LCD (e.g., peripheral arterial disease)
- All medically necessary services for all component conditions of the terminal prognosis are the hospice’s responsibility along the continuum of care
- The principal diagnosis and other prognosis-impacting conditions need to be re-evaluated as dictated by the patient’s clinical course and included in the physician’s documentation, interdisciplinary assessments, and plan of care
- CMS expects hospices to report secondary diagnoses on claims (more when we discuss relatedness)
- As of 10/1/14, debility and adult failure to thrive can no longer be designated as principal hospice diagnoses. They can, however, be listed as comorbidities/secondary diagnoses that are contributory to the terminal prognosis
- Dementia (290-295) cannot be used as the principal hospice diagnosis. It is the manifestation of an underlying condition (e.g., cerebral atherosclerosis), which should be named as the principal hospice diagnosis with dementia as a secondary condition
In summary, CMS is making the point that the Medicare Hospice Benefit has always defined the terminal illness, not as a single diagnosis, but as the interplay of conditions that together cause an individual to have a prognosis of 6 months or less. At this point, the proposed definition is open for comments. However, my guess is that in the final determination, although the two have at times been used interchangeably by the hospice community, there may well be a clear differentiation between the definition of ‘terminal illness’ and that of the ‘principle/hospice-qualifying diagnosis’ to better underscore the prognostic implication and comprehensive nature of the former. In the meantime, CMS will be paying attention to how terminal illness is being defined and addressed in the care of hospice patients. Ongoing documentation in the clinical record should very clearly reflect the hospice physician’s and team’s recognition of the complex and multifarious nature of terminal illness, and the assumption of full responsibility for its palliation along the continuum of care, thereby continuing to “(make) good on their promise to do a better job than conventional Medicare services for those who (are) at end-of-life.”
* All quotations are from the Final Rule referenced above
Posted by Suzanne Karefa-Johnson, MD, Senior Physician Consultant, Weatherbee Resources, Inc.
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