The 2018 Wage Index and Payment Rate Update for Hospice includes significant wording differences compared to the current Conditions of Participation. These differences may cause hospice agencies to feel that they now must cover more medications. The Wage Index wording
- “…hospice to cover all reasonable and necessary palliative care related to the terminal prognosis, as well as, care for the interventions to manage pain and symptoms, as described in the beneficiary’s plan of care.” This suggests covered symptoms are not limited to only the 4Ps of hospice (pain, poop, puke, and psych) but now include any and all symptoms/discomfort the hospice patient experiences.
- “…unless there is clear evidence that a condition is unrelated to the terminal prognosis, all conditions are considered to be related to the terminal prognosis and are the responsibility of the hospice to address and treat.” This is an ongoing debate between hospices and Medicare. In 2014, CMS tried to increase hospice coverage of “maintenance” medications by requiring Medicare Part D prior authorization for every medication once a patient elected hospice enrollment. This lasted less than 6 months. Both Medicare Part D plans and hospice agencies were soon overwhelmed with paperwork and patients went without necessary medications. CMS went back to relying on hospices to determine the relatedness of a medication.
Why the push for hospices to take responsibility for more medications? High Medicare costs make CMS question:
- Whether everything that should be hospice covered is being covered.
- Whether all medications prescribed are medically necessary (correct dose, duration, diagnosis.)
- Whether all medications are appropriate for the patient’s age, gender, clinical condition, and
cause of symptoms.
In a June 2017 open letter to CMS administrator Seema Verma, the NHPCO pro-actively voices concern regarding any future changes to the Conditions of Participation. Edo Banach, President and CEO of the NHPCO states “No additional changes in the requirements [in the Conditions of Participation] are warranted” and goes on further to address other causes for the high Medicare costs.
At this time, we recommend that you continue to cover terminal condition + related and 4P symptoms including additional medications on a patient-by-patient basis and that you start utilizing deprescribing tools such as STOPP/START and the BEERS List. Use the questions below in addition to “Is this medication related or unrelated?” when completing an initial medication review. Note that HospiceMed has an in-service available to help develop these skills as well.
If your nurses have a good understanding of best practices in medication management + deprescribing, your hospice will be leagues ahead of other agencies when CMS officially updates the Conditions of Participations and mandates broader medication coverage.
1. “Medicare Program; FY 2018 Hospice Wage Index And Payment Rate Update And Hospice Quality Reporting Requirements.”
Federal Register. N. p., 2017. Web. 25 Nov. 2017.
2. https://www.nhpco.org/sites/default/files/public/regulatory/NHPCO_Comment_Letter_FY2018_Proposed_Rule.pdf [Accessed 25
3. “Rxpassport.” Rxbriefcase.com. N. p., 2017. Web. 25 Nov. 2017.
4. ” A Practical Guide To Stopping Medicines In Older People – BPJ 27 April 2010 .” Bpac.org.nz. N. p., 2017. Web. 25 Nov. 2017.
5. “Deprescribing: A Simple Method For Reducing Polypharmacy.” Mdedge.com. N. p., 2017. Web. 25 Nov. 2017.