10/11/2011
HOSPICE MEDICAL NECESSITY
SUPPORTINGTHENECESSITYOFCARE
PROVIDEDBYTHEHOSPICEIDTAPPROACH.
PresentedbyNancySharpBSNCHPN
DirectorofProgramIntegrityforIowaHospice
HOW DO YOU PROVE CARE IS MEDICALLY NECESSARY WHEN THE GOAL IS NOT MEDICAL?
• Hospicecareisintendedforpeoplewhoare
nearingtheendoflife.Unlikeothermedical
care,however,thefocusofhospicecareisn't
tocureortreattheunderlyingdisease.The
goalofhospicecareistoprovidethe
highestqualityoflifepossiblefor
whatevertimeremains.
http://www.mayoclinic.com/health/hospice‐care
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TITLE 42 – 418.3
Hospicecaremeansacomprehensivesetof
servicesidentifiedandcoordinatedbyan
interdisciplinarygrouptoprovideforthe
physical,psychosocial,spiritual,and
emotionalneedsofaterminallyillpatient
and/orfamilymembers,asdelineatedina
specificpatientplanofcare.
Authority:Sections.1861(dd)(1)oftheSocialSecurityAct
(42U.S.C.1302and1395hh).
Subpart C ‐ Conditions of Participation – Patient Care 418.56(a)Theinterdisciplinarygroupmust
include,butisnotlimitedto,individualswhoare
qualifiedandcompetenttopracticeinthe
followingprofessionalroles:
• i.Adoctorofmedicineorosteopathy(whoisan
employeeorundercontractwiththehospice
• ii.Aregisterednurse
• iii.Asocialworker ‐ Definitionchangedin2008
• iv.Apastoralorothercounselor
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Subpart C ‐ Conditions of Participation – Patient Care 418.56(c) Theplanofcaremustincludeall
servicesnecessaryforthepalliationand
managementoftheterminalillnessand
relatedconditions,includingthefollowing:
• (1)Interventionstomanagepainand
symptoms.
• (2)Adetailedstatementofthescopeand
frequencyofservicesnecessarytomeetthe
specificpatientandfamilyneeds.
Plan of Care Requirements Cont.
• (3)Measurableoutcomesanticipatedfrom
implementingandcoordinatingtheplanofcare.
• (4)Drugsandtreatmentnecessarytomeetthe
needsofthepatient.
• (5)Medicalsuppliesandappliancesnecessaryto
meettheneedsofthepatient.
• (6)Theinterdisciplinarygroup'sdocumentationof
thepatient’sorrepresentative’slevelof
understanding,involvement,andagreement
withtheplanofcare,inaccordancewiththe
hospice’sownpolicies,intheclinicalrecord.
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Subpart C ‐ Conditions of Participation – Patient Care §418.64Conditionofparticipation:Core
services.Ahospicemustroutinelyprovide
substantiallyallcoreservicesdirectlyby
hospiceemployees.
Theseservicesmustbeprovidedinamanner
consistentwithacceptablestandardsof
practice.Theseservicesincludenursing
services,medicalsocialservices,and
counseling.Thehospicemaycontractfor
physicianservices.
(b) Standard: Nursing Services
• Nursingservicesmustensurethatthe
nursingneedsofthepatientaremetas
identifiedinthepatient’sinitialassessment,
comprehensiveassessment,andupdated
assessments.
Note:HospiceAideServicesarenon‐core
servicesandareassignedandmanagedby
thedesignatedRNCaseManager.
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(c) Standard: Medical social services. • Medicalsocialservicesmustbeprovidedby
aqualifiedsocialworker,underthe
directionofaphysician.Socialwork
servicesmustbebasedon thepatient’s
psychosocialassessmentandthepatient’s
andfamily’sneedsandacceptanceof
theseservices.
(d) Standard: Counseling services. Counselingservicesmustbeavailabletothe
patientandfamilytoassistthepatientand
familyinminimizingthestressand
problemsthatarisefromtheterminal
illness,relatedconditions,andthedying
process.Counselingservicesmustinclude,
butarenotlimitedto,thefollowing:
(1)Bereavementcounseling
(2)Dietarycounseling.
(3)Spiritualcounseling.
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Subpart F—Covered Services • Tobecovered,hospiceservicesmustbe
reasonableandnecessaryforthe
palliationormanagementofthe
terminalillnessaswellasrelated
conditions.Theindividualmustelect
hospicecareinaccordancewithSec.418.24
andaplanofcaremustbeestablishedasset
forthinSec.418.58beforeservicesare
provided.Theservicesmustbeconsistent
withtheplanofcare.
Sec. 418.202 Covered services.
• Allservicesmustbeperformedby
appropriatelyqualifiedpersonnel,butitis
thenatureoftheservice,ratherthanthe
qualificationofthepersonwhoprovides
it,thatdeterminesthecoveragecategoryof
theservice.Thefollowingservicesare
coveredhospiceservices.
(a)NursingServices
(b)SocialServices
(c)PhysicianServices
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Sec. 418.202 Covered services.
• (d)Counselingservicesprovidedtothe
terminallyillindividualandthefamily
membersorotherpersonscaringforthe
individualathome.Counseling,including
dietarycounseling,maybeprovidedbothfor
thepurposeoftrainingtheindividual'sfamily
orothercaregivertoprovidecare,andforthe
purposeofhelping theindividualandthose
caringforhimorhertoadjusttothe
individual'sapproachingdeath.
Lessons From Other Health Agencies
• Hospital DRGsarebasedupondetailed
codingandrecentregulationsrelatedtore‐
hospitalizationalongwithqualitymeasures.
• SNF haspagesoflistedservicesthatmeetor
donotmeetmedicallynecessaryservices,
suchasmaintenancecareofaG‐Tube.
• HomeHealthhasrequiredsubmissionof
Oasisformtosupportlevelofmedical
necessity,numberofreasonablevisitsand
services.Minimaluseofanyservicesother
thannurse/aide.
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Challenges to Hospice Reimbursement Related to Necessity of Services
• MEDPACrecommendations in2010wasto
alterreimbursementmethodologyandcreate
“U‐shapedcurve“withhigherpaymentat
beginningandend/deathwheregreater
serviceneedsareidentified;Congress
includeddirectiveinHealthcarereformbill
·MEDPACreferredto‘dark’sideofhospice
industryinrelationshiptorapidincreasein
numberofhospiceagenciesandpatientload
andpotentialchangeinmotiveforprovisionof
services.
Hospice Quality Concern
Qualityofcare—
‘‘Wedonothavesufficientevidencetoassess
quality,asinformationonqualityofcareis
verylimited.Effortscompletedorunder
waymightprovideapathwayforfurther
developmentofqualitymeasures’’.
*MedPac2010report
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Health Reform Enacted
• HOSPICESMUSTREPORTONQUALITY
1.ToMedicareby2012
…….ortakea2%reduction.
2.TotheGeneralPublicby2014
Howwillqualityscoresrelatetothe
evaluationofthemedicalnecessityof
hospiceservices?
Health Reform Expansion
Value‐basedpurchasingprogramsfor
long‐termcareproviders,including
hospiceproviders,byJan.2016.
ThegoalofVBPistorevamphow
Medicareservicesarepaidtobetter
rewardvalue,outcomesand
innovationsinsteadofbasingpayment
merelyonvolume.
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CGS “Cigna Government Services”
MAC for Iowa Since June 2011
• UpheldpreviousLCDrequirementsformedical
necessityofadmissiontoMedicareHospice
Services.
• CIGNADefinition:Exceptwherestatelawor
regulationrequiresadifferentdefinition,
“MedicallyNecessary”or“MedicalNecessity”
shallmeanhealthcareservicesthatare
provided,exercisingprudentclinicaljudgment,
clinicallyappropriateandbygeneralStandards
ofPractice.
CMS Initiated Visit Reporting ‐ 2008
• CMSisutilizingaphasedincreaseindata
requiredofhospices,inordertoimprove
hospicebenefitpaymentaccuracyand
analyzetheservicesprovidedinthis
evolvingandgrowingbenefit.
• CMSrecognizesthatthereportedvisitsdo
notrepresentallcareprovidedunderthe
hospicebenefit.
• ReportinghasexpandedtoincludeSWcalls.
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When Reporting Visits: What is “medically reasonable and necessary”? Per CMS
• Services(visits)reportedmustbereasonable
andnecessaryforthepalliationand
managementoftheterminalillnessandrelated
conditions,asdescribedinthepatient’splanof
care.
• Tasksshouldnotbedistributedacrossmultiple
visitsforthepurposeofinflatingthepatient’s
visitcount.
• CMShasclarifiedthat,forsocialworkers,
counselingorspeakingwithapatient’sfamily
orarrangingforplacementwouldconstitutea
visit.
Examples of Reactions to Medical Necessity Language
1. Medicare/MedicaidaddsFacetoFacevisits
inof2011bythehospicephysicianorARNP.
2. MontanaMedicaidPlanofCaretosupport
billingaddssectionforacuityofneed.
3. MagnoliaHealthPlaninLouisiana/Mississippi
addspreauthorizationbaseduponmedical
necessityofservices.
4. CIGNAPrivateInsuranceidentifiesnon‐
MedicallyNecessaryservices.
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2. Montana Medicaid Plan of Care Requires Severity Coding
PROBLEM SEVERITY CODES
0– NoProblemIdentified
1‐ Problem– Controlledattimeof
assessment
2‐ Mild– Functioncouldbeimpaired
3– Moderate– Abletofunctionwithsupport
4– Marked– Abletofunctiononlywithdaily
intervention
5– Severe– Incapacitatedbytheproblem
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Medical Necessity Qualified to Determine Visit Frequency 3. Magnolia Health Plan Change:
• EffectiveAugust15,2011,therequired
documentationtosupportmedicalnecessity
forhospiceadmissionswill
change. MagnoliaHealthPlanwillrequirein
additiontothephysiciancertification,a
patientelectionform,ahistoryand
physicalbytheattendingphysicianwith
theterminaldiagnosislisted. Allhospice
priorauthorizationswillbeevaluatedfor
medicalnecessityusingthemedical
necessitycriteriadevelopedbythe
LouisianaMississippiHospiceandPalliative
CareOrganization.
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4. CIGNA PRIVATE INSURANCE
CIGNAdoesnotcoverANYofthefollowing
hospicecareservicesbecauseeachis
specificallyexcludedfromcoverageoris
considerednotmedicallynecessaryas
hospicecare(thislistmaynotbeall
inclusive):
servicesforindividualsnolongerconsidered
terminallyill
services,suppliesorproceduresthatare
directedtowardscuringtheterminalcondition
4. CIGNA PRIVATE INSURANCE, cont.
servicestoprimarilyaidinthe
performanceofactivitiesofdailyliving
nutritionalsupplements,vitamins,
mineralsandnon‐prescriptiondrugs
medicalsuppliesunrelatedtothe
palliativecaretobeprovided
servicesforwhichanyotherbenefits
apply
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Supporting Medical Necessity of Nursing Services
 Areastobeaddressedareidentified
thrutheskillsofnursingassessment.
 Needtoincludeobjectivemeasurement
scalesandincludepatient/caregiver
goals.
 PlanofCareaddressesinterventions
neededtoreachobjectivegoallevel.
 Mustinvolvedirectpatientcareand
assessmentateachvisit.
Supporting Medical Necessity of Nursing Services, cont.
 Documentateachvisitwhatplanofcarearea
ofneedorinterventionisbeingprovidedor
assessedforeffectiveness.
 Interventionrequiredforanyissueassessed
tobeoutofacceptablegoalrange.
 Familyorcaregivercontactrequiredforany
changeininterventionsoroutcomes.
 Anychangeininterventionrequires
reasonablefollowupforeffectiveness.
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Supporting Medical Necessity of Nursing Services, cont.
Patient/PCGgoalsneedcontinual
assessmentforongoingchanges
throughoutthehospicecare.
• ForMedicalReviewpurposes:
 eachclaimbilledstandsaloneandrequires
•
sufficientsupportoftheongoingmedical
necessityofthehospiceservicesbeing
provided.
 allinterventionsmustbeindirectresponseto
theestablishedplanofcare.
Supporting Medical Necessity of Social Worker Services
• Areastobeaddressedareidentifiedthru
theskillsofsocialworkerassessment.
• Equalassessmentofthepatientandthe
family/patientcaregiversisrequired.
• Planofcareinterventionsmustbe
acceptabletothefamily/PCGandthis
acceptanceneedstobedocumented.
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Objective Measurement to Support Social Worker Services
• SWAT“SocialWorkerAssessmentTool”
Qualitativeinterviewingofthesocialworkers
inpilotusetestindicatedsomelackof
readinessinthefieldtoconduct
quantitativeoutcomesmeasurement.
Additionalmeasuresareneededinaddition
totheSWAT,includingqualitativemeasures,
andmeasuresofmezzoandmacropractice.
JSocWorkEndLifePalliat Care.;7(2‐3):263‐80
Objective Measurement to Support Social Worker Services
BereavementRiskAssessments
GeneralSafetyRiskAssessments
FallRiskAssessments
SuicidalRiskAssessments
MiniMentalExamswithtimeframe
comparisons.
• FamilySatisfactionOutcomesrelatedto
identifiedpreferences
•
•
•
•
•
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New Initiatives in Determining Preferences
• TheWallStreetJournal:TheInformed
Patient:NewEffortsToSimplifyEnd‐Of‐Life
CareWishes Theprogramsareknownas
PhysicianOrdersforLife‐Sustaining
Treatment,orPolst.
• APolst,whichissignedbyboththepatientand
thedoctor,spellsoutsuchchoicesaswhethera
patientwantstobeonamechanicalbreathing
machineorfeedingtubeandreceiveantibiotics
New Initiatives in Determining Preferences
• WBUR'sCommonHealthBlog:Massachusetts
UnveilsPlanForBetterDying[The]
"MassachusettsExpertPanelOnEnd‐Of‐Life
Care"...laidoutitsplantodayforhowthestate
canbegintoimprovetheend.
• everypatientwithaseriousillnessthatmay
befatalshouldbefullyinformedofthe
rangeofwaystheymightbetakencareof....
patientpreferencesshouldbeknown,
documented,andalwaysavailablewhen
decisionsaregoingtobemade. ...3‐14‐2011
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Iowa Hospice PIP “PCAT”
• ThePCATscorecardwasdevelopedtoidentify
psychosocialneedsaspartoftheHospicePlan
ofCareandtoevaluatetheIDTresponsein
addressingtheseneedsforimprovedoverall
patientcareoutcomes.
• Responsetoidentifiedneedsshouldbetimely
andreassessedbythe30thdayofcare,and
againatthefirstrecertificationdateifpatient
remainsonservice.
• 16areasassessedwithtotalscoreof16‐48
possible.Urgencyandfrequencyofresponseis
drivenbyscore.
Areas
Assessed
Awareness
of Prognosis
1
2
3
Point
Points
Points
Stable
Unwilling
to
Complete In Process discuss
Legal
Decision
Maker
Unwilling
to
Complete In Process discuss
Stable
Score
Date:
Unwilling
to
In Process discuss
Funeral
Plans
Patient
Caregiver
Established
30 Days
Admission Score
Need
Immediate
Identified
Need
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Iowa Hospice PIP “PCAT”
• Byselecting16primaryareastoassessfor
immediateintervention,focuswithinthe
first30daysismorelikelytocapture
patient/PCGneedsinatimelyfashionin
relationshiptothedecreasedmedianlength
ofstayinhospice.
• Thepatient/family/PCGattentionisfocused
onpreferencesinawaytoenhance
outcomesbeingmet.
• Solidifiesthenecessityofsocialworker
services.
Supporting Medical Necessity of Counseling Services
• Unexploredservicearea‐ Visitsarenot
presentlymeasuredbyMedicare.
• CompetencyandPreparationvariesgreatlyas
noconsistentrequirementsforservingin
“Chaplain”roleduetolimitedavailability
acrossthecountry.
• Wide‐rangeofresponsetoconceptofproviding
“spiritualcare”withgovernmentfunding.
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Supporting Medical Necessity of Chaplain Counseling Services
• Lookatpatient/family/PCGasagroupclient
andasseparateclients.
• UseaformalAssessmentTooltoimprove
consistencyincare:EXAMPLE:
H:Sourcesofhope,meaning,comfort,strength,
peace,loveandconnection
O:Organizedreligion
P:Personalspiritualityandpractices
E:Effectsonmedicalcareandend‐of‐lifeissues
Barriers to Supporting Medical Necessity of Dietary Counseling Services
• Notviewedasaprimaryfocusareaatendof
lifeandremainsunderassessed.
• Manyculturalnormsrelatedtofood
continuetoaffectendoflifedecision
making.
• Continuousstigmarelatedtotheconceptof
naturaldeathvs.withholdingnutrition.
• Majorportionisstillhandledbynurses.
• AssistedLivingbarrierstospecializeddiets.
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Supporting Medical Necessity of Bereavement Counseling Services
• Expandeddefinitionin2008COPsupdates
enhancedtheroleofpre‐deathbereavement
care.Notareimbursedservicesonotas
scrutinizedformedicalnecessity.
• Servicesshouldbeprovidedinrelationship
toBereavementRiskAssessmentsand
individualizedplanofcare.
• Increasednumberofgeographicallydistant
bereavedcomplicatesprovisionofservices.
• Needtoidentifycomplicatedbereavedfor
externalreferrals
What about Non‐Core Services
• AideServices
• PT/OT/ST
• AlternativeTherapies:Massage/Music/Pet
• What“InnovativeServices”willweseein
thefuture?
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GROUP INPUT
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