Schumacher Message on Terminal Prognosis
A Message from Don Schumacher: Thinking in Terms of Terminal Prognosis
March 5, 2015
As providers of hospice care, we must reframe the way we think about and characterize our patients and the scope of our responsibility in providing care to them, shifting from submitting a single diagnosis on the claim form to providing a more comprehensive and accurate picture that validates each patient’s eligibility for hospice care by focusing on the basis for their terminal prognosis.
Download our Talking Points on Using Terminal Prognosis.
Determining what aspects of care hospice providers are responsible for has become an issue of growing importance in recent months.
Ever since the Medicare hospice benefit was established, “terminally ill” has been defined as “having a medical prognosis that the individual’s life expectancy is six months or less.” Eligibility for the hospice benefit has always hinged on the patient having a terminal prognosis, regardless of the underlying cause or causes.
Over decades of practice in our field, some hospice programs have tended to characterize their responsibility to patients by a single diagnosis, as evidenced on Medicare claim forms. As analysis of CMS claims data has shown, 72 percent of providers submitted only one diagnosis on the claim form even though we know that for many of our patients, their terminal prognosis is based on a combination of diagnoses and conditions.
While CMS does require a primary diagnosis on the claim form, the primary diagnosis often is only part of what should be reported to provide the more comprehensive portrayal of the reason for the patient’s terminal prognosis.
There is significant concern from regulators and on Capitol Hill that by relying on a single diagnosis, hospice providers may be defining their scope of responsibility too narrowly, ultimately failing to provide and coordinate all the care and services that they should.
MOVE TO PROGNOSIS
As providers of hospice care, we must reframe the way we characterize our patients, shifting from a single diagnosis to a more comprehensive depiction that utilizes all diagnoses and conditions that contribute to each patient’s terminal prognosis, thereby establishing their eligibility for hospice.
The question can be asked: “Does this diagnosis or condition contribute to or influence the patient’s terminal prognosis?” If so, then it is our responsibility.
Yes, this is likely to increase our responsibilities in a number of ways, but it is the right thing to do.
No professionals are more skilled or have greater expertise at managing comorbidities than our nation’s hospice and palliative care community. NHPCO strongly believes it is the hospice physician who can, and must, be the one to provide the most accurate and timely clinical picture of the individuals receiving hospice care.
NHPCO is in constant dialog with leaders and senior policy makers at CMS and hospice’s responsibility is an area of intense and active discussion. And our discussions are ongoing.
CMS has been very receptive to the proactive steps taken by the hospice community to paint a more comprehensive picture of our patients.
Let me be very clear here, by being more proactive with regards to hospice’s responsibility, we are likely to avoid CMS implementing more draconian changes, changes that might be far more challenging for us to deal with.
NHPCO’s Relatedness Workgroup – made up of hospice physicians, clinicians and hospice administrators – has been tackling this issue for the past 18 months, discussing the hospice’s responsibility and the process a hospice would use to determine which of the patient’s diagnoses and conditions would be related. Information is available in the Regulatory Section of NHPCO’s website – including the “Determining Relatedness to the Terminal Prognosis Process Flow Chart.” Additional tools will be developed.
We will continue to share more information on the hospice’s responsibility in terms of prognosis in the months ahead, and this will certainly be one of the areas of training at this spring’s Management and Leadership Conference.
Our dedication and resolve have served us well in our past and will allow us to continue our shared mission.
J. Donald Schumacher, PsyD
President and CEO