President Obama signed the IMPACT Act into law on October 6. The law had overwhelming bipartisan support and will bring increased federal oversight to hospice programs across the country. The legislation mainly addresses how nursing homes, rehab-centers, and home health agencies assess and report data on quality and other measures. However, buried in the new law are provisions that improve the frequency of hospice inspections and allow Medicare to review programs in which a large volume of patients receive long hospice stay. The Act requires inspections every three years and funds $70 million over 10 years to make that happen.
Prior to the IMPACT Act, Medicare sought to conduct surveys on hospice care every six years, but after, budget cuts increased that to every eight years. On the other hand, home health agencies are being surveyed every three years and nursing homes inspected every fifteen months. President of the National Hospice and Palliative Care Organization, J. Donald Schumacher, states “depending on the state, you can get a hospice license in this country and not get surveyed for seven to fifteen years.” With the standing dismal state of federal hospice oversight, the IMPACT Act moves in the right direction, but is it enough?
In recent years, the number of hospices has grown rapidly. In 2005, there were about 2,500 organizations caring for about 870,000 patients. This number increased in 2011 to 3,600 organizations caring for 1.2 million patients. Hospices started out as a large nonprofit local effort, but over the years have changed into an industry. For-profit hospices now make up the majority of the field and many are associated with national chains. Today, for-profit hospices represent 63 percent of hospices, compared to 1990, where only five percent of hospices were for-profit.
This switch to big industry has seen a spike in disenrollment rates of hospice patients. The Medicare Payment Advisory found that around twenty percent of hospice patients are discharged alive, with hospices, not patients, being the driving force behind discharges. The relationship between hospice industry and disenrollment rates is increased profit.
Medicare reimburses hospices at a fixed daily rate, regardless of how long they care for a patient. However, some days cost more than others. The trend shows that in the first days of care, the family and caregivers are extensively involved with a plan of care for the patient. The middle days of care are called the stable days, in which cost of care is profitable for for-profit hospices. The later days, when a patient is near death, are when costs substantially rise.
A Mount Sinai/Yale study suggests that for-profit hospices recruit patients, keep them enrolled for long stays, and then discharge them when cost of care no longer proves profitable. Essentially, these for-profit hospices are dumping patients for dying too slowly. In the end, this ends up costing Medicare more money. For example, discharged cancer patients may end up in emergency rooms and intensive care units at great costs. These are expenses that may have been avoided if these patients were still enrolled in hospice care.
With these glaring flaws in hospice care, how does the IMPACT Act intend to help? Greater inspection of hospices is a needed step in the right direction, but how big of a difference will it really make?
There are three national accrediting organizations that have authority for hospices: the Joint Commission, CHAP, and ACHC. Many hospices are accredited by one of these three organizations. To be accredited, the hospice agrees to inspections and must meet higher standards of care than those hospices that are not accredited. When selecting hospice care, many families look to this as a valuable indicator of quality. Hospices that are accredited by one of these three organizations must meet Medicare regulations and be surveyed once every three years. While the IMPACT Act will extend inspection to non-accredited hospices also, one must wonder how big of a difference frequent surveys will make when a big percentage of hospices already undergo inspection.
The IMPACT Act brings progress to the table in hospice care. It may not be the panacea for the cracks in the current system, but it is a stepping-stone to a solution. Other future suggestions for hospice management may be having hospices list disenrollment rates so that caregivers looking for hospice care will be discouraged from selecting a hospice that discharges a high rate of patients. Another proposition is revising Medicare payments to hospice companies to eradicate the financial incentive for negligent care.