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NHPCO Responds to USA Today

NHPCO Comments on USA Today Article

By Edo Banach, JD
President and CEO
August 3, 2017

In the USA Today article, “Taking too long to die: Some 'terminal' patients can lose hospice benefits” journalists Frank Gluck and Melanie Payne examine some of the challenges with caring for people with serious illness, particularly those who no longer qualify for hospice care under the Medicare hospice benefit. Situations involving “live discharges” are complex issues that can be misunderstood.

Live Discharges

NHPCO stresses the importance of not assuming live discharges may reflect improper behavior on behalf of a hospice provider.

As the authors share in the article, approximately one in six patients are discharged from hospice care while living. Live discharges have always been seen within hospice care in the U.S. and can occur because a patient’s condition improves or stabilizes (as in the USA Today article), a choice is made to resume curative-focused care, or a patient leaves hospice care for other personal reasons that can vary, such as moving out of a hospice’s service area.

There is confusion about hospice discharges that warrants clarification. In MedPAC’s most recent report (Report to the Congress, Medicare Payment Policy, March 2017) citing 2015 Medicare data, they report that for all reasons, hospices discharge roughly 17 percent of their patients “live.”  But, MedPAC goes on to note that hospice-initiated discharges based on patient eligibility comprise only about seven percent of the figure, with the remainder being about six percent patient revocations, two percent transfers to another hospice program, one percent because the patient moves out of the hospice service area, and less than one percent of patients are discharged for cause.

Length of Service Concerns

It must not be assumed that a person under the care of hospice for longer than 180 days no longer is eligible for care. However, that individual must still be recertified by a physician as qualifying for care under the conditions of participation as specified by the Centers for Medicare and Medicaid Services (CMS). NHPCO’s most recent facts and figures report indicates that while 50 percent of hospice patients died or were discharged within 14 days of admission, only 10.3 percent were under care for longer than 180 days.

As discussed in the most recent MedPAC report, Medicare – which began offering a hospice benefit in 1983 – covers palliative and support services for beneficiaries who are terminally ill, with a medical prognosis that the individual’s life expectancy is six months or less if the illness runs its normal course.  While the eligibility criteria uses a six-month prognosis as its determinant, hospice benefits are available to the patient and family for an unlimited duration, as long as the patient continues to meet the eligibility criteria, which is assessed at specific intervals.  In other words, Medicare hospice benefits are available to all terminally ill beneficiaries for an unlimited period of time, as long as they continue to have a six-month prognosis.

Hospice is a Risk-Pool Model

At its inception, the Medicare hospice benefit was designed as a risk-pool financial model, assuming a mix of short, medium and long stay patients whose care would be reimbursed under a relatively flat payment scheme. One way to view this model is to think of it as Medicare’s first foray into managed care, providing hospice programs with a set amount of reimbursement per day, from which the hospice would have to manage all of the expenses of care related to the patient’s terminal prognosis.  From the beginning, safeguards were built into the model and have remained in place, with strong support from the hospice community, throughout its history to ensure that patients meet the eligibility criteria and get the right care at the right time.

Determining Eligibility

Both Congress and CMS have been clear about the role of the hospice physician and their role in certifying and recertifying eligibility for hospice services, and the hospice community takes this responsibility very seriously.  The Medicare administrative contractors, hired by CMS to process hospice claims and review eligibility, have understood that prognosis is as much an art as a science and tend to ask hospice programs to “paint a picture” of the patient’s condition to support eligibility, rather than rely on a check-box system, or strict adherence to a set of published criteria.  This system has, in most instances, worked well to expand the number of patients electing Medicare hospice services at the end of life.

When an existing hospice patient no longer meets the six-month eligibility criteria, a process should be in place to inform, in a timely and thoughtful manner, the patient and family so that other arrangements for care may be made to accommodate the patient.  Understanding the status and complexity of today’s health care system, this isn’t always a smooth transition or totally satisfactory to the patient and family.  Hospice is an inclusive and comprehensive set of trained professionals and compassionate services, provided wherever the patient finds themselves, and similar health care settings rarely offer the same care model.  But, hospices are required to discharge patients, after appropriate planning, when the patient no longer meets the eligibility criteria of six months or less, as determined by CMS.

While hospices once cared predominantly for cancer patients at life’s end, providers now are skilled at caring for a wider range of patients with multiple complex conditions. In 2014, 63 percent of patients cared for had a non-cancer diagnoses. To see changes in care provision patterns over time should be expected to some degree.

NHPCO believes that the overwhelming majority of U.S. hospices are committed to a shared vision to bring the best that humankind can offer to all those individuals facing serious illness, death and grief. Within that vision, however, is the duty of each provider to do the best job possible to ensure that every single patient day of care is within all regulatory and legal limits.


NHPCO also shares the letter to the editor of USA Today that was submitted to the publication when the article appeared.

August 1, 2017

Dear Editor:

A clarification is needed in response to the article, “Taking too long to die: Some 'terminal' patients can lose hospice benefits.”  It’s not that Medicare will “allow” a hospice to discharge a patient that no longer is certified as terminally ill but that Medicare requires providers to so.  Federal efforts focused on compliance have made it clear that hospices must not care for people who are not, or are no longer, terminally-ill.

Mr. Tagtmeir is not experiencing a problem with hospice care – as it currently exists. The problem is with a health care system that’s unable to provide the necessary long-term care to Americans and their families with serious illness that are not actively dying, and therefore not eligible for hospice care under the Medicare benefit.

Hospice provides coordinated care across settings and improved quality of life for patients and family caregivers that meet current hospice criteria.  Hospice and palliative care providers are anxious to work on innovations that make the high-quality, compassionate care we provide more accessible to all those in need.


Edo Banach, JD
President and CEO
National Hospice and Palliative Care Organization