A very tangled web

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Providers must facilitate constant communication among patients, family and themselves.
Providers must facilitate constant communication among patients, family and themselves.

The consequences of medication management in hospice care pose powerful implications for providers. Medicare and private payers constantly fiddle with reimbursement rules while the costs of pharmaceuticals and negligence litigation continue skyrocketing. 

Behind the scenes there is a great deal of stress.

Today, the Medicare hospice program covers about 84% of all hospice patients. Medications continue to take bigger slices of the total cost of their care, according to the General Accounting Office. Today, hospice care can easily topple $10,000 a month. 

Meanwhile, patients are staying in hospice longer than ever. According to the National Hospice and Palliative Care Organization, the average length of stay rose from 69.1 days in 2011 to 71.8 days in 2012. 

In 2012, the inspector general for the Centers for Medicare & Medicaid Services warned the agency that it was paying twice for prescription drugs such as analgesics, antiemetics, laxatives and anxiety meds for beneficiaries enrolled in hospice. The quandary involved two major payers — Medicare Part D and the hospice per diem program. CMS determined that the Medicare Part D program was not an appropriate place to seek reimbursement for drugs related to a terminal illness.

As more duplicative and inappropriate billing problems surfaced, Medicare told providers in early January 2014 that it would begin heavily investigating claims involving hospice medications.

Two months later, it dropped a bomb.

Payments denied

In a March 10 memorandum, the agency instructed Part D program participants to initially deny payments and require prior authorizations for all prescribed hospice medications. This forced patients and their families into a quagmire of lengthy and costly appeals to get their bills paid.

The provider community was livid. As one consultant pharmacist who asked to remain anonymous said, “When Part D and hospice coverage squabble over who will cover the meds, the result is a sick patient, in pain, not getting meds at the end of life while the bean counters dither. Egregious.”

In mid-July, after a series of meetings with industry officials and patient advocates, the agency revised its policy, requiring prior authorizations only for analgesics, anti-nauseants, laxatives and anti-anxiety drugs.

Payment rules for hospice medications remain baffling and complex.

“Who ultimately pays for hospice drugs can get complicated because there's not always an agreement among payers,” says Gary Erwin, Pharm.D., senior vice president of clinical services, Omnicare. 

Rob Shulman, the director of Clinical Services for Remedi SeniorCare, thinks the shifting rules challenge patients and hospice pharmacies in ways they never have before. 

“Hospice and Part D plans have been forced to create a ‘prior authorization' process to differentiate coverage of medications between the two payers,” he says. As a result, hospice patients are vulnerable to going without vital pain and anxiety medications such as concentrated morphine sulfate because of prescription delays resulting from restrictions in controlled substance laws.

Blame yourself

Some say operators may be seen as their own worst enemy.

Earlier this year, the Medicare Payment Advisory Commission suggested freezing hospice reimbursements for 2015, something that didn't come as good news to an industry that has seen its margins plunge recently. This provides yet more impetus for hospice providers to better manage their drug costs, particularly those inside nursing homes, according to Heather Hudson, medication compliance specialist for Parata Systems.

“Billing and documentation become tricky when a patient is in a long-term care setting,” she says. “Hospice may bill for services related to the diagnosis or cause of the end of life and that is usually a combination of diagnoses and related symptoms. Poor communications between care providers often leaves gaps in documentation, leading to gaps and discrepancies in billing.”

Providers also are facing the specter of being penalized for rehospitalizations — an outgrowth of current healthcare reform efforts. One major adverse drug event, even for a dying patient, could be disastrous.

A recently published study in Health Affairs discovered that about 10% of hospice patients have an emergency department visit or hospital stay during their last month of life. Still, Richard Greene, Pharm.D., a fellow of the American Society of Consultant Pharmacists and senior director of regulatory affairs for CareKinesis, believes hospices have a very positive track record. 

“Nursing home residents who are enrolled in hospice are significantly less likely to be sent to the hospital at the end of life,” he says.

Pain, shortcomings

As if the thing that's killing them isn't bad enough, end-stage cancer patients present with a plethora of symptoms such as fatigue, pain, weakness, weight and appetite loss, anxiety, constipation, dyspnea, dry mouth and depression, according to Hospice Pharmacia, which promotes itself as expert in the management of end-of-life medication. Use of multiple medications, including central nervous system depressants, is a common and often unavoidable consequence of hospice and palliative care, the group maintains.

“In a hospice long-term care setting, excessively complicated medication schedules leave room for error,” notes Emeritus Professor of Medicine James F. Fries, M.D., Stanford School of Medicine, whose research has focused on patients with chronic diseases.

Despite extraordinary efforts hospice providers expend to comfort the dying, some observers feel there is remarkably little anyone truly understands about how to better manage their medications.

Doctors can assume part of the blame. According to the American Hospice Foundation, many physicians and other healthcare professionals never get adequate training in “how to expertly manage pain and other symptoms when they were going through school.” Even in the face of “expert clinical guidelines” on pain management, many physicians actually under-dose with hospice patients, the group asserts, noting studies that have shown as many as 85% of patients suffer through advanced stages of cancer with “significant pain.”

“Under-dosing is common, and often families and some care providers are afraid to utilize medications fully based on unfounded fears,” says Jeff Lackman, RPh, divisional vice president for Rx RemoteSolutions & Rx ResourceSolutions, a division of comprehensive pharmacy services.

“Prescribers often do not know the strength of medications in hospice because it is not something they deal with every day,” adds Courtney Oland, RPh, director of pharmacy operations for Waltz Long Term Care Pharmacy, a locally owned member of the Guardian Pharmacy family. “This leads to prescriptions written for incorrect drug concentrations and/or unrealistic quantities.”

Adds Erwin: “It often comes down to fragmentation of our healthcare system, a scenario in which multiple physicians may be treating different parts of a patient, and that can create problems like drug interactions and other adverse events.” 

Prescribers need balance

Physicians constantly have to strike a balance between the therapeutic effect of a drug, which is analgesia, versus sedation, which in excess can lead to adverse consequences, Erwin notes.

“Most adverse drug events in hospice are an extension of the therapeutic effect,” he says. “Consider narcotics. All you want is for their pain to go away. But that same narcotic can cause respiratory difficulties, constipation, blurred vision, drowsiness, and there's no such thing as a narcotic that only relieves pain and not create any of those other things. Really good hospice programs understand the need for this balance. They're maximizing the benefit they're seeking while minimizing the risks, and that's challenging as hell.”

Pharmacists aren't immune, either. As Hudson explains, “using multiple pharmacies, in my experience, can cause a multitude of medication errors, medication duplication and medication contraindications — all at the expense of the patient.”

Providers themselves also are culpable. It can be understandable because of the often-frenetic transitions from hospitals to hospice units, which unwittingly and abruptly discontinue medications “deemed no longer necessary based on the election of the hospice benefit,” says Shulman. And many do this despite 8-year-old CMS guidelines that advise providers to taper off dementia, cholesterol and urinary incontinence medications in hospice patients.

“Despite this warning list, medications are still discontinued abruptly without taper and patients continue to experience adverse effects as a consequence,” Shulman notes.

The tragically human side

In the closing days for a hospice patient, there are decisions made in facility hallways, at a nurse's station, in a physician's office, or over the telephone – many concerning medications to provide comfort. The conversations are often emotional. 

“There are all kinds of pressures placed upon hospice caregivers by families, who may say they don't want to see their loved ones suffer,” Erwin says. “It comes down to how much they are willing to resolve an issue such as pain and they make those decisions in very personal ways. Good providers know how to manage that pressure.”

“When patients can't participate in the decision making, families and other advocates and caregivers sometimes have vastly different sets of expectations to an end-of-life care situation,” observes Stephen Evans, M.D., a hospitalist with IPC The Hospitalist Company and medical director of the Terrace View Long-Term Care Facility in Buffalo, NY. 

For hospice patients who are fortunate to have their wits when death draws near, the challenges of too much medication use are often easier to manage, adds Evans, who routinely consults with area hospice providers and authored an article in the British geriatrics journal Age and Aging about the analytics of frailty as a potential yardstick for the application of palliative care.

“These are all very personal and unique decisions,” he adds. “Some patients may decide they are willing to be sleepy in order to be free of pain. While others may decide to dial down their pain medicine so they can have the kinds of emotionally laden discussions they need to have with parents, spouses, siblings or grandchildren.”

Caregivers have learned to be very careful when it comes to decisions about the administering of medications, and the conversations can vary widely in tone from one participant to another. 

“The expectations for care vary considerably yet once we ask, we need to be mindful that the extent to which we ask or don't communicate those wishes to other people doesn't unwittingly set up others for failure,” he adds.

Lessons learned

History shows that any industry under a great deal of scrutiny either reforms itself or becomes irrelevant. Long-term care hospice is an example of the former.

In its independent review for CMS, Abt Associates cites new research calling for the development of quality measures to address inappropriate prescribing in hospices.

Similarly, providers recognize the need for everyone to better understand the issue of pain management in a dying person. For example, facilities need objective pain scales and to “own” how a resident is reacting to a specific medication, Bill Vaughan, vice president of education and clinical Affairs at Remedi SeniorCare, has told McKnight's

Furthermore, the industry has come to acknowledge that pharmacists are pivotal in medication management and in advocating for pain management in patients, says Lackman. 

Greene expands on this idea, saying that hospice organizations have come to rely on pharmacists to provide enhanced clinical services to support the interdisciplinary team. For example, pharmacists might provide advice on acute symptom management and alternative routes of administration, anticipation of disease progression and opioid dosing calculations. 

There also have been some calls to directly integrate pharmacists on interdisciplinary hospice teams to improve patient care. 

“Pharmacists play a critical role on those teams,” adds Fries. “They can help to negotiate a plan that is as simple as possible to avoid medication management problems, and put systems in place to ensure accuracy.” 

Finally, everyone agrees that hospice should fully embrace palliative care — one of the key tenets of healthcare reform.

A pilot program for terminally ill veterans earlier this year found that patients were more likely to receive the proper medications for pain and anxiety when staff were fully trained in palliative care measures.

“This is an area of almost daily focus for me in my clinical practice,” says Evans. “Good medication management is absolutely a part of the palliative process and begins with having the conversation with the patient about expectations.”

Omnicare's Erwin agrees: “Hospice in principle and, hopefully, practice is a healthcare approach that is done by individuals skilled in palliation. When it's done right, it's a minimalization of drug therapy. It's a touch point of therapy to palliate symptoms. It comforts. Anything that deviates from that, I believe, is where you begin to see less than optimal care and management of that patient.”