Journey of the End of a Lifetime: Let’s Add Hospice

by Joanna Smith on Jul 21, 2016

I am working with an amazing, compassionate physician in helping P.S. end her life. He has thoughtfully put together a protocol for the patients he is working with (to me they are clients, but that’s another discussion!). He is not “just” an End of Life prescribing doctor: he talks with people about all the options for them as they approach the end of their lives, and he has referred patients to Advanced Illness Management Programs and Palliative Care if they are really not a candidate for Aid in Dying.
Part of that protocol is that they agree to enter into Hospice care as part of his work with them if they do quality for Aid in Dying.

A Complex Wrinkle (and short course in Medicare, for those unfamiliar with it)
P.S. is currently in a nursing home with Medicare Part A (which covers in-patient, skilled care) covering her for Rehab services (think: physical therapy and occupational therapy). P.S. has told me she not longer wants rehab (“I can’t do it and I’m not getting stronger”). So I talk with the Director of Nurses at the Nursing Home and let her know that P.S. wants Hospice, and the nurse agrees to discontinue the Medicare Part A rehab billing so P.S. can access her Medicare Part A Hospice benefit: you cannot “double dip”: either Medicare Part A covers rehab in a nursing home OR they will cover Hospice in a nursing home, not both. P.S. will then have Hospice in the nursing home, and Medicaid will cover her room and board there until we can bring her home in a few days, once the Aid in Dying is set up.

Can you see where this is going?

I coordinate with Hospice, they send a nurse to the nursing home to enroll P.S. in Hospice, and find that the nursing home has not DIS-ENROLLED her from her rehab benefit, so Hospice can not ENROLL her in Hospice. Why? Payor mix is probably a large part of this. Medicare’s reimbursement for a day in a nursing home is much higher than Medicaid’s, so it is to the nursing home’s advantage to keep her on the rehab payment rate rather than the Medicaid rate.

I am furious when I hear this, but a quiet, determined furious. I go to the nursing home and talk with the CEO, saying this is not right: their patient is requesting Hospice, and we cannot bring it in because they are refusing to stop billing under rehab to Medicare. What I don’t say, but he understands clearly, is that this is Medicare fraud.

Sometimes the unsaid is more powerful than the said.

The issue is quickly resolved; her Rehab benefit is discontinued that day. Because this has been stressful for P.S., she decides to go home the next day and Hospice will ENROLL her that afternoon at home. While the facility is surprised, they offer to provide her transport home at their expense. We all–P.S., the physician, Hospice and myself, give a huge sigh of relief.

Next Post: Home to Die
BEST PRACTICES FOR HEALTHCARE ADVOCATES: pick your battles wisely and remember that quiet determination can produce far better results, frequently, than aggressive confrontation.