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

Cheryl Clark, for HealthLeaders Media, June 6, 2013

At some point, he continues, clinicians are now starting to say, if patients like this one will go into hospice soon in the near future, "Why couldn't we move them into hospice quicker?"

He's also concerned that these clinicians—increasing numbers of whom are employed by hospitals—will take it a step further, encouraging hospice designation for patients for whom the question of hospice appropriateness is less clear.

"There may be someone who is very old, a 93-year-old man comes in with an MI (myocardial infarction). Should they go to the cath lab or not? They have no other medical problems. What should be the level of care? What is the expiration date on a person? Is it 90 or 80, or after one procedure or two?

"There are people in the [federal] administration who believe that the only way to really solve the high cost of healthcare is to ration care," Kupfer says. He doesn't think that's a good direction for national policy.

Kupfer, a practicing cardiologist, doesn't stop there with his concern.

"My question really is, are incentives constructed around physician behavior morally ethical? Should a physician get paid extra for what [he or she is] supposed to do in the first place, like prescribing beta blockers or ace inhibitors?

"And when you have incentives like this, and hospitals have financial interests in the incentives, what kinds of processes do they put into place to make sure they win the incentives. There's a balance between positive and negative effects."

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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.