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Hospitals' Fear of 30-Day Penalties May Speed Hospice Admissions

Cheryl Clark, for HealthLeaders Media, June 6, 2013

An exception to federal 30-day mortality measures may incent hospitals to prematurely push patients into hospice care, says one critic, who calls it an unintended consequence of healthcare reform.

To avoid 30-day mortality penalties, hospital clinicians are aggressively steering newly admitted patients into hospice rather than usual inpatient services if they are at high risk of dying soon.

That's the rather caustic view of Joel M. Kupfer, MD, director of interventional cardiology at 336-bed Methodist Medical Center in Peoria, IL, who describes what he believes is another chapter in the healthcare reform book of unintended consequences.

Kupfer expressed his thoughts in a Viewpoint published in this week's Journal of the American Medical Association.

"The policies that hospitals and clinicians will implement to avoid being saddled with a mortality they are not in a position to predict or prevent should not be underestimated," Kupfer writes.

His words sound harsh. After all, wasn't part of the whole idea behind healthcare reform to give patients at the end of life a choice about how to spend their last days, and avoid futile, often painful, expensive care in surgical suites and intensive care units if that's not what they'd want?

Does he really think physicians will prematurely push patients into hospice care? That, I would think, would be tantamount to malpractice.

So I asked Kupfer to explain what he thinks is going on, and why he believes federal payment rules are steering us off the tracks and into the dreaded swampland of—yes, he dared say the word—"rationed" care.

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5 comments on "Hospitals' Fear of 30-Day Penalties May Speed Hospice Admissions"


James Sinclair, M.D. (6/27/2013 at 4:10 PM)
Excellent point and counter-point. CMS will soon be making public outcomes data regarding our own patient's 30 day mortality rate from agressive intervention such as last chemotherapy given. If peer review could put pressure on us to see our failure in appropriate hospice referral then I agree we wouldn't need payer oversight.

Michael D. Fratkin,MD (6/14/2013 at 9:08 AM)
If the effect of the ridiculous 24 hour timeframe is that hospitals dig deeper to resource and staff Palliative Care programs, I can live with the social engineering of the federal guidelines. It seems more likely, at least in my neck of the woods, that already strapped community hospitals will just try to lean on their underfunded, understaffed, and under-resourced Palliative Care "Teams" (I am a "team" of one) to impossibly improve this metric. The desired outcome is to accelerate the conversations that define patient and family desires and values to occur prior to the initiation of any treatment plan....at admission. The culture change required to give time and space for this discussion at the moment of admission is vast. It's not going to be successful putting a Palliative Medicine provider into every hospital admission process. Rather, it will be nessecary for the incentives to favor the TIME it takes to have these conversations at admission by the admitting physician/provider. The pace, pressure, workloads, lean staffing, rising documentation requirements, and the quantification of 'quality medical care' all work to speed the admission process up and pull the provider from the central human dilemma of our patients understanding the reality of their circumstances and choosing their own path. The solution awaits us at the bedside if our systems can accommodate another 15-30 minutes to meet these people on their own terms rather than in terms of their role as data in an industrial medical machine.

T R Patterson (6/12/2013 at 4:18 PM)
As an HPM doc who practiced so far 35 years, I feel there is merit in the claim that incentives will be followed by actions. Anyone who doesn't see this has not watched medicine evolve. BUT, the real question, I feel, is WHY are doctors not asking questions that raise end of life care and getting answers long before the terminal hospitalization. A large percentage of elderly patients, and those with life limiting diseases are KNOWN to be at risk well before. We as doctors have allowed (encouraged?) the myth that we can fix anything and extend life for over two generations! Are we surprised now when no one wants to ration care or allow death to be a natural part of life? We must get directives before the crisis develops- it is too hard in a crunch for most patients and families to suddenly confront death when they have been misled for so long that it won't happen.