home hospice vs nursing home hospice

Tuesday, February 27, 2007

Home Hospice -vs- Nursing Home Hospice: The Difference

I recently wrote again that I believe hospices should be paid a different amount depending on if the patient lives at home or in a nursing home. I know some people disagree, and I understand that. I also understand their argument, so I wanted to take a moment here to explain my stance.

It is true that hospices are required to provide the exact same care for nursing home patients as they provide for home patients. There is zero difference in the Medicare regulations for these two types of patients. In fact, Medicare regulations do not distinguish these two categories at all. This is, in large part, the argument that people use when defending the fact that there is no difference in pay between home and nursing home patients. If we are supposed to provide the exact same services to patients no matter where they live, then why should we get paid different depending on where they live?

Good question. The answer is simple and comes in three parts.

Part one. Hospice is required to provide whatever you need for your terminal illness. What you need depends on any number of factors, but where you live is one of the biggest. If you live in a nursing home, you already have someone giving you a bath at least three days a week. At home hospice will give you your bath every day. In a nursing home, you have easy access to a medical professional to answer your little questions. At home you call hospice for every little thing. At a nursing home, there is a nurse in the building who will talk you through a panic attack. At home, you call the on-call nurse. In a nursing home, you have a professional who dispenses your medications when it is time to take them. At home, you do it yourself, and call the nurse when you can’t remember if you took your pills. Nursing home patients, by definition, live in a safe environment, so the Social Worker’s role is less complicated. Home patients, require more frequent Social Work visits and community resource linking that can take hours of the Social Worker’s time. Obviously the list could go on much longer, but you get the point. While hospice does offer the exact same services to home patients and nursing home patients, home patients take us up on the offer much more frequently.

Part two. There is no travel time between two nursing home patients. This saves money in two ways. If you have to see two patients and they live 10 miles apart, then the hospice pays you $4.05 (or so) to make the drive. If you see six patients that day, the hospice pays $24.30 for your travel expenses. If you see six patients in the nursing home, the hospice pays you nothing for travel. That’s $486 per month for every employee that doesn’t have to drive from one patient to another. The even bigger cost savings comes from the increase in productivity you achieve when you don’t have to drive ten minutes between every patient. If every visit takes one hour, then you can do eight nursing home visits each day. Six home visits would be the max, because of travel time. Thus, a home visit costs more because of travel time and mileage reimbursement.

Part three. I have saved the biggest for last. There is a difference in the types of diagnosis that you find in home patients and nursing home patients. Generally, a nursing home will have a high number of dementia patients or “adult failure to thrive” patients. Most all cancer patients are home patients. CHF and COPD are also more commonly found in the home. Cancer patients have more pain problems, expensive pain meds, and unexpected changes in their symptoms than dementia patients. CHF and COPD increase the need for medical equipment and anxiety medications. In short, cancer is the most expensive diagnosis to a hospice; especially one that is willing to do things like palliative radiation or palliative chemo. Dementia patients require far less from the Chaplain and Social Worker. I know that Hospice Pharmacia, which works on a flat daily rate, charges different rates for cancer and non-cancer patients because cancer patients have much more expensive pharmacy bills. It is just fact that the types of diseases you treat in the home are more expensive to manage than the types you treat in the nursing home.

Yes, I know there are examples out there that will poke a hole in most everything I have just written. Those are exceptions to the rule though. There are no exceptions to rule number two above, and I am confident that rules one and three hold very true.

Home patients cost more money than nursing home patients. That is fact. The debate is whether Medicare should pay hospices a different amount depending on where you live. My guess is that your answer to that question will depend greatly on your company’s ratio of home patients to nursing home patients. I do believe that if, as President Bush has proposed, hospice rates are reduced across the board, those who take care of more home patients than nursing home patients will have trouble staying in business. Once we are gone, who is going to help you stay at home during your final months?

Either tell me where I’m wrong or tell me how to make this happen. Congress won’t make these types of changes without someone telling them that the changes are appropriate, so how do we do that? This is a subject we can’t ignore much longer.

7
comments:


tlmoorebsw
said…

You do have very valid points on the difference between the care needed for home verses facility patients. You don’t address patients in assisted livings with can be as complicated as home patients. My concern about a reimbursement variance for home/nursing home patients is that there are hospices out here that will adjust the amount of care/supplies/visits provided to nursing home patients based on that reimbursement. Also, for those of us (for Profits)in states without a Medicaid hospice benefit, that small mileage savings helps us offset the cost of caring for those nonfunded patients that currently account for greater than 10% of my current census. I am afraid that changing reimbursement rates based on location is the equivalent of throwing the baby out with the bathwater.ik


danielc
said…

Such is the drawback of a capitated system. A hospice interested in serving all eligible patients (ie ANY patient that qualifies based on clinical criteria) may make a responsible decision to broaden their patient pool to find “the less expensive patients that help us finance care for the more expensive ones.” But a capitated system creates the potential for an agency to make a financial decision to seek out only the inexpensive patients – playing by the rules but essentially gaming the system. Decreasing the rate for SNF patients will cause hardship for agencies using the “broaden the risk pool” strategy.


Anonymous
said…

Actually, I work for Hospice Pharmacia. We charge the same daily rate for every patient whether he/she has cancer or any other terminal diagnosis. Our rates differ ONLY for home care patients & facility patients. The beauty of our system is that we can manage pharmacotherapy in order to provide needed drugs for all our patients, no matter what their diagnosis, at a reasonable daily rate.


Anonymous
said…

Being a “Nursing Home Doc” as well as Medical Director of Long Term Care Hospice, I can tell you that any cuts in reimbursement of facility based hospice care will be counter productive and greatly reduce quality of care. Most of my families are very appreciative of having the hospice team take care of various services such as bathing, feeding, wound dressing changes etc. because these patients for the most part have not received adequate care due to shortage of nursing home staff etc. Also remember that patient’s family is paying for the nursing home staff to take care of their loved one in form of “room and board charges” and not medicare so why should they not receive and expect the same medicare benefit for their loved one as a patient who is signed into hospice as a “home patient” ? Nursing home is in essence home for these people as well. Should we provide different medicare hospice benefits or reimbursement to hospices based on the financial capabilities of the home patient’s families?


Anonymous
said…

One thing you failed to mention is that at least in Idaho, many SNF patients are on Medicaid, which absorbs some, or maybe all of the room and board charges. When hospice enters the picture, the SNF can no longer bill Medicare OR MEDICAID for the R& B charges if the patient elects hospice. If the client is Medicaid, the SNF must now bill the hospice for the R&B; charges, and the hospice bills MEdicaid, who can, by statute, take up to 90 days to pay the bill, PLUS the hospice takes a 5% hit but must still pay the SNF 100% of the R&B; charges.Yes you have the option to bill the patient for the 5%, but since they are already on Medicaid, what’s the chances you are going to collect? Taking even more from hospices serving patients in SNF’s amounts to a denial of service to the SNF patients, because they will NOT be able to afford the patients. Not a good solution.


Anonymous
said…

Actually I believe you do not have to pay the SNF 100% of the Medicaid rate you could pay the 95%. I believe it may actually be more work for the nurses and Aids and such in ALF or SNF because of the Communication breakdowns and lack of control over what the SNF or ALF do. Even with much education they still can cause many headaches for the Hospice. I hear nurses say they would rather have a home patient then a facility patient.

Another question why does medicaid only reimburse the Hospice 95% instead of a 100%?


Anonymous
said…

My mother is currently a resident at a local nursing home. She is terminally ill and I am considering Hospice care in this facility. Many of the nurses of this facility, including the DON feel there is no difference in the care they provide and the care the Hospice will provide. The facility nurses tell me they do the same thing Hospice does. Being ignorant to this industry I am a little confused and suspicious. If Medicare provides Hospice care then there must be some differences. In a nutshell can someone please tell me the the advantages of Hospice care in a nursing home and the differences in care that will be received from Hospice? Is it financial gain for the facility to not have Hospice? Thank you.