NHPCO Member Communication -- Critical Access Hospitals

To:        NHPCO Members From:   Public Policy Team Date:     November 11, 2004 Re:       Critical Access Hospitals

NHPCO is receiving increasing numbers of calls regarding the relationship between hospices and Critical Access Hospitals (CAH) and the difficulty hospices are facing in contracting.  Over the last several months, NHPCO has been working with CMS and the Health Resources and Services Administration (HRSA) to identify the specific issues and determine what solutions are available.  At the meeting with the CMS Regional Office in Chicago on Tuesday (11/09/04), CMS Central office representative Terri Deutsch reported on the results of the investigation she has been doing. 

1. Hospices can contract with the CAH.The hospice pays for the inpatient stay for the patient, CMS does not specify the amount that the hospice pays to the CAH for the inpatient stay.The contractual arrangement is a business decision between the hospice and the CAH.The hospice may contract for either routine acute care or as a part of a swing bed.
2. Hospice general inpatient days DO count toward the CAH%27s per diem, as figured in the annual CAH cost report.Many Critical Access Hospitals are very concerned because the difference between the hospice%27s daily rate for general inpatient care and the CAH%27s reimbursement rate for a day of inpatient care are often hundreds of dollars apart, and the CAH%27s per diem rate could decrease for all types of inpatient care that is provided if many hospice inpatient days are provided.Unfortunately, there appears to be NO regulatory authority to exclude hospice days from the inpatient day count in the CAH cost report. NHPCO is pursuing on a variety of possible solutions to this problem.
3. The CAH admission requirements are also a difficulty for hospice providers.The hospice general inpatient level of care is not equivalent to an acute hospital admission, because the hospice general inpatient level of care allows the hospice to admit a patient for caregiver breakdown, an admission not familiar to Critical Access Hospitals.Some hospices have had trouble admitting hospice patients to a CAH when caregiver breakdown is the primary reason for the admission.

We realize what a difficult burden this is placing on patients and their families who need hospice care, and the hospices who serve them.  Unfortunately, there is not a short-term solution to this problem.  We have worked closely with CMS to look for authority to make changes that will help hospices continue to contract with CAHs and will exhaust all efforts to find a resolution.

It will be helpful to continue hearing specific stories about your hospice%27s concerns and problems contracting with Critical Access Hospitals, so that we can use them to advocate for the necessary legislative changes. We will be working collaboratively with other national associations involved in rural issues as well, so that we can get a speedy resolution to this vexing issue. Specific cases are helpful, as well as details about contracting, admission issues, or the inability of the patient to receive needed inpatient care. 

Send your thoughts and comments to NHPCO at jlundperson@nhpco.org.