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.