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

Cheryl Clark, for HealthLeaders Media, June 6, 2013

"Rightly or wrongly, most people associate hospice with, 'You're going to die.' And some families are not very eager, or are even reluctant to make that decision quickly," he says. The timing of 24 hours, and the rush to designate hospice before the clock strikes, is what bothers him.

I asked Harlan Krumholz, MD, who helped formulate the rule and its exceptions with the Centers for Medicare & Medicaid Services, what he thought. He called it "anti-measurement hysteria."

"There's no measure on earth that's going to protect against someone like that. That's a person who shouldn't be practicing medicine."

But Kupfer says shifts to more hospice designation have already begun. "From what I see, more of us are more aggressive in recommending hospice for some of our patients with more severe illnesses."

Until the mortality part of the incentive payment kicked in, here's what usually happened when a certain "high-risk-of-dying" patient, say someone in her 80s or 90s, came into the hospital from a nursing home, Kupfer says.

"She has Alzheimer's, strokes, atrial fibrillation, and a urinary tract infection and a little heart failure. The discussion with the family isn't, 'let's put her in hospice.' It's 'We don't think she should be treated aggressively, but we'll give her some diuretics and maybe an antibiotic. And if she turns around, we can send her back to the nursing home.' "

Without a hospice designation that day, if that patient dies within 30 days, she'd count against the hospital's mortality score, "even if the family did designate hospice care for her four or five days later," Kupfer says.

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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.