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.
The issue, he says is new 30-day mortality measures federal payers have woven into the healthcare reform law's value-based purchasing algorithm for incentive payments starting October 1. Hospitals with higher numbers of pneumonia, heart failure, or heart attack patients who die within 30 days of discharge during the performance period (the latest one ended June 30, 2012) will fare poorly in their overall VBP score.
That's because the weight of those three measures affects 25% of 1.25% of the hospital's Medicare base DRG payments.
But written into the rule is a key exception that Kupfer says has not gone unnoticed by clinicians and the hospitals that employ them:
If patients are designated for hospice care during their first 24 hours of their hospital stay, and then die within 30 days of discharge, they aren't counted against the hospital's score.
Is Kupfer saying that physicians will be a little quicker to enter high-risk, older patients with multiple health issues into hospice, resulting in them not getting care that could benefit them and extend their lives?
"Right," he replies. "I'm concerned that hospitals will exert pressure to move patients into hospice, even if they're appropriate patients for hospice, but will do it within the first 24 hours. Even if it puts them at odds with families," who need more time to make that important and emotional decision.
"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.
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."
Cognizant of the penalty, not to mention the public reporting and notoriety, hospitals across the country are taking steps to beef up their hospice and palliative care programs.
"There's no doubt that hospitals are aggressively pursuing palliative care and hospice strategies for their patients," Kupfer says. "And there's no doubt they're aggressively hiring physicians to be able to provide much more rapid evaluation for palliative and hospital care… and have made it part of their strategies for reducing readmissions and also, therefore, mortality."
Overall, Kupfer is "questioning the morality" of using financial incentives to make doctors and hospitals do what they should be doing anyway, giving the right care at the right time.
So what should we do instead? Do we throw out all of our incentive programs and not require quality measurement in how we deliver care? Kupfer thinks peer review should come into play.
But for me, that's not going to cut it. We've had peer review for a very long time. It hasn't worked.
Maybe, just maybe, the recognition that hospice care is more important should prompt these conversations earlier, before that moment of confusion and crisis when the patient is back in the hospital, and no one knows what to do.