A new Medicare rule requiring a doctor or nurse practitioner to visit patients in person after 180 days of hospice care is likely to raise staffing costs for providers and could limit the reach of assistance in rural areas.
The rule, which goes into effect today, requires a face-to-face visit before a hospice patient can continue to receive care after two 90-day periods. However, Medicare agreed Dec. 23 to postpone enforcing the rule until April 1 to give providers more time to meet its requirements.
The primary functions of the visit are to make sure that the patient still needs end-of-life care and that the care is appropriate for the person's needs.
The goal of hospice care is to provide comfort to a patient who is close to dying rather than to continue treating the patient to extend his or her life. Some hospice care is provided in facilities, and some involves visits to patients' homes. Care is provided by medical professionals and lay volunteers.
Local and state officials said the rule would affect about 9 percent of North Carolinians who receive hospice care.
Where the cost comes into play is that Medicare will not allow a provider to bill for the doctor or nurse practitioner visit. It's considered an administrative requirement, so the bill must come out of Medicare's per diem rate of about $130 a day.
"It's going to stretch all of us, no question about it, more so with the smaller hospices," said JoAnn Davis, the president and chief executive of Hospice & Palliative CareCenter, which is based in Winston-Salem and serves 13 counties.
Many smaller hospices rely on physicians to volunteer their time for in-home visits, but the new rules will require more visits.
Davis said the center is preparing to have face-to-face visits with 114 patients in January.
It recently has hired a full-time physician to help handle the visits, along with expanded internal services at its facilities. Davis said the center should learn this month whether state regulators will allow it to expand by 10 beds to 40.
Medicare pays 100 percent of the cost of hospice care for most recipients, and it covers 80 percent of hospice care in the country. An additional 10 percent is covered by Medicaid for low-income or disabled people, while the rest is covered by private insurance or self-pay.
Requirements include: The patient must be eligible for Medicare Part A; a physician must certify the patient is terminally ill with a six-month or less life expectancy; and the patient must sign a statement acknowledging he wants hospice care instead of standard Medicare benefits for medical treatment.
"If the visit requires reasonable and necessary nonadministrative patient care, such as symptom management, that part of the visit could be billable (to Medicare)," said Cindy Morgan, the associate vice president for innovations and professional development for the Association for Home & Hospice Care of N.C. The doctor has to be the patient's designated attending physician to qualify for billing.
Davis said that although the center will lose money overall on the new rule, "its purpose is very noble. Some hospices will allow a patient to stay, even after they have stabilized. We won't keep a patient under hospice care if it is not appropriate."
Davis said the center's hospice cases tend to mirror the rate in the state — about one third of patients die within a week of starting care and about half die within three weeks.
Dana Swicegood, the director of quality and compliance with Hospice of Davidson County, said the nonbillable aspect of the visits in most cases "will have a significant impact on hospices serving rural areas."
"By having hospice doctors provide these face-to-face visits, it reduces the time they have to provide care and communicate with the nursing staff," Swicegood said.
rcraver@wsjournal.com
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