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Hospice Evolution Positive for Physicians, Patients
By Vanessa Orr

Keith LagneseNot that long ago, many people hadn’t even heard of hospice, and the services that it provided were not well understood. While the idea of hospice is certainly more familiar today, there are still some misconceptions that exist.

“Fifteen or 20 years ago, it’s like hospice was a secret,” explained Dr. Keith Lagnese, MD, FACP, HMDC, chief medical officer of Family Hospice and Palliative Care. “It’s a wonderful thing that more people today, including patients, providers and long-term care facilities, know about the services we provide. There are a number of reasons for that, including the fact that we’re dealing with more educated consumers; palliative care is now a medical subspecialty, and that hospice has been publicized in the media—unfortunately, sometimes as part of Medicare fraud articles.”

According to Dr. Lagnese, about 90 to 95 percent of hospice patients are cared for at home, which is defined as a personal residence, assisted living facility or nursing home. While some people still think of hospice as an actual building, it is far less common for patients to be treated in general inpatient unit of care, such as at hospitals, or in freestanding inpatient units.

What makes a patient eligible for hospice can also be a source of confusion. “Generally, two physicians must certify that a patient’s prognosis is six months or less to live with a terminal illness,” explained Dr. Lagnese, adding that the patient is covered for an indefinite amount of time as long he or she continues to meet eligibility standards.

According to the doctor, in the early 1980s, it was easier for physicians to prognosticate a patient’s length of survival based on the cancer model. “Most of the patients then, about two-thirds, were cancer patients,” he explained. “Now, only one-third of patients have a cancer diagnosis, which makes it more difficult for physician and healthcare providers to predicate survival following the guidelines for dementia and other non-cancer diagnoses.”

To combat fraud, as well as to enable physicians to become more involved in hospice patients’ care, Medicare made some changes to the hospice benefit in 2011. “Twenty years ago, hospice was really a nurse-run industry; a hospice physician signed a lot of paperwork, but didn’t need to provide a physician narrative about why the patient needed hospice; he or she just checked a box if the patient was terminally ill,” explained Dr. Lagnese. “Medicare began requiring face-to-face encounters in 2011—after the first six months, a physician or certified nurse practitioner is required to examine and evaluate the patient.

“This is good for the industry and the patient—it empowers physicians and lets them become more involved,” he added.

This has also changed how many hospices are run, with many choosing to move from a part-time to a full-time medical director. “What’s happening at better hospices and with physicians is that they are seeking out some sort of specialized hospice training and/or certification,” said Dr. Lagnese. “There is now a fellowship in hospice and palliative medicine, which 15 years ago didn’t exist.”

In January 2016, Medicare also made changes to how hospices were reimbursed, changing a daily fixed rate to rates that vary depending on where a patient is in the process. “After the first 60 days of care, the rate goes down, because most resources are utilized during the first several weeks when patient needs tend to be greater,” said Dr. Lagnese. “The rate goes up again during the last 5-7 days of life because the need for excess nursing, physician, and social work visits goes up.”

Medicare is also now requiring more data on clinical care, in the hopes that improved reporting will rein in fraud and enable patients to make more appropriate choices as better quality data becomes available.

While these changes are all good for the industry, there are two misconceptions that Dr. Lagnese would still like to see cleared up. “People tell me that they thought that they weren’t ‘sick enough’ for hospice because they thought that it was only for people in their very last days of life,” he said. “I also hear that they wish they had known about hospice sooner or that their doctors had referred them sooner. They didn’t know that they had the possibility of having hospice help them earlier.”

To learn more about Family Hospice and Palliative Care, visit www.FamilyHospicePA.org.

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