The Rising Dilemma: Discharged From Hospice Care

January 15, 2014

Almost everyone has heard of hospice care, or had a loved one who received hospice care at the end of their lives. Hospice nurses are generally a very special group of people who do a phenomenal job, caring and shepherding the patient and family through end of life issues. While visiting the sick of my parish, I have come across something that used to be much more rare–patients being discharged from hospice care. It’s a tremendous dilemma for the patient and family.

Hospices have always been able to discharge some patients under their care. The Medicare Payment Advisory Commission, relying on 2009 and 2010 data, has reported that 20 percent of hospice patients are discharged alive each year. Things are changing. Discharges are climbing. The largest hospice in Maryland reports that they now discharge about 20 percent of their  patients, and “we’re on the low side,” said its clinical director. Further illustrating this upward trend in discharges, a Washington Post investigation, analyzing a million records of California hospice patients, found that the proportion of hospice patients discharged alive rose 50 percent between 2002 and 2012.

While most hospice patients remain in hospice care until they die, discharge may be initiated either by the patient and family or by the hospice program, for reasons that include:

  • The patient or family is not satisfied with the hospice program and wants to choose another provider.
  • The patient moves to a residence outside the hospice program’s service area.
  • The patient improves and no longer needs hospice care; in this case, the doctor will not continue to certify periods of care. In some cases where there is significant improvement in the patient’s condition, the hospice may discharge the patient even before the current period of care has ended.
  • The patient desires curative treatment, which is not provided in hospice.
  • The patient or family fails to comply with the plan of care.
  • There are serious issues of safety, for the patient or staff, which cannot be resolved.

If the hospice program does not provide in-patient hospice services, it must have a written transfer agreement with a hospice program that provides those services, and they must assist with arranging the transfer when necessary.

There have been several theories posed, as to why the number of discharges from hospice care has increased:

  • Families have been urged to contact hospice earlier in the patient’s illness–and then, are sometimes discharged if the patient temporarily stabilizes or doesn’t decline (no good way to say this) “fast enough.”
  • The Centers for Medicare & Medicaid Services (CMMS), who oversee hospice care and payment,  are looking much more carefully at longer-stay patients. With hospices under increasing government oversight, hospices must be more careful about the patients they admit and the patients they keep.

CMMS claims reviewers look to see whether a patient’s disease is progressing. They are looking for measurable evidence, for example, increases in medication, oxygen or decreased mobility in the patient. In other words, concrete signs the patient’s condition is worsening. Unfortunately, if you have cared for someone at the end of life, you know there are plateaus and even some temporary improvements–this can lead to a discharge from hospice.

Why should a hospice program be so concerned about the eligibility of their patients? They have no choice. If CMMS holds up or denied reimbursement to a hospice program due to patients that CMMS has found to be possibly ineligible, the financial fallout can be devastating. Medicare audits forced a nonprofit San Diego Hospice, to close earlier this year; denied expected payments, the hospice owed millions of dollars and declared bankruptcy. At the same time, the recent federal sequester reduced payments by 2 percent. With other cuts, Medicare reimbursements to hospices are predicted to be about 4 percent lower this year. Bottom line, a hospice can’t afford to risk non-payment if the patient has become ineligible.

There have been reports that many of the discharges from hospices are more related to corporate greed among for-profit hospices. It is suggested that some hospices enroll ineligible seniors for long stays, take their profit, and then discharge them before they experience Medicare sanctions. The Justice Department has sued several large national chains to stop these practices.

The problem is the people and families who sign up for hospice, and then end up discharged–with a patient who still needs care, based upon a stable weight or unchanged need for oxygen.

It is very important to know, that if your loved one has been discharged from hospice care, you can appeal the decision, and you can re-enroll if the patient’s condition worsens.

Appealing an Involuntary Discharge

When hospice programs initiate discharge, it is usually because the patient has improved and is no longer eligible for hospice care. When the patient is no longer eligible due to improvement in his or her condition, the insurance company will no longer pay for hospice care. Patients have rights to appeal denials from Medicare, Medical Assistance, the Department of Veterans Affairs, and private insurance companies. Contact the insurance company for information about the appeals process.

Re-enrolling in a Hospice Program

If the patient’s condition changes and he or she is discharged from hospice care, re-enrollment is possible when the patient again becomes medically eligible for care. A patient who has chosen to leave a hospice program may re-enroll in hospice care if medically eligible for service.