Similar but Not the Same - Palliative Care v. Hospice

The Center for Medicare and Medicaid Services (CMS) states that hospices are the largest providers of palliative care services in the country (CMS, 2018). However, palliative care and hospice care are quite different. According to CMS, palliative care focuses on relief from physical suffering. The patient may or may not be terminally ill yet may be treated for and living with a chronic disease. All stages of disease are treated through palliative care, which addresses the disease and uses life-prolonging medications in a multidisciplinary approach.

Hospice Care (HC) is available to terminally ill Medicare participants and each state has different guidelines for the length of life expectancy used to decide qualification for care. HC does not use life-prolonging medications or treatments. The patient is helped to be comfortable, and the family to prepare for end of life. Hospice “relies on a family caregiver and a visiting hospice nurse” and is usually offered at the location the patient prefers (home, nursing home, or sometimes a hospital).

But there are other differences as well. Turn-Key Health, “an Advanced Illness Management (AIM) company, serving healthcare payers and at-risk provider organizations that focus on an aging population” (2018), states on their website that “based on FFS (fee for service) billing through Medicare Part B, most community-based palliative care programs utilize nurse practitioners and physicians for home visits. Other disciplines, such as nurses and social workers, cannot bill Medicare for palliative home visits.” This is a very important point. When a patient elects hospice, Turn-Key states “they sign off their Medicare Part A (hospital insurance) and enroll in hospice under the MHB”, Medicare Hospice Benefit. One of the implications of this is that hospital stays will typically not be paid by CMS unless the condition for which the patient hospitalized is unrelated to the terminal diagnosis. Under the MHB, the patient is not billed directly for hospice care, but care not related to the terminal illness or related conditions is still paid through original Medicare.

Let me give you an example of how I learned of this fact. Dad was at breakfast and had what appeared to be a syncope episode but remained unresponsive afterward. Mom and the caregiver just couldn’t get him to respond in any way to what they were saying. He was pale and slumped over in his chair. Mom called the agency we had signed up with (to provide what we were led to believe was palliative care) and asked for the nurse to get there stat. The agency staff said a nurse was not available, so mom called EMS. Dad was taken to the local hospital emergency room and had tests to determine what had caused the episode. He had experienced another syncope episode that was more prolonged than typical due to dehydration. He came home from the hospital later that same afternoon.

Several weeks later, mom received dad’s Medicare statement that the bills were denied and would not be paid. The charges amounted to over $8,000! Amidst her panic and worry about how they would pay this bill, I did some research, protested the claim, and it was paid in full because syncope was not related to the diagnosis for which he qualified for services, the nurse at the agency was unavailable, etc. Make sure you document what transpires should you have a similar situation. It could save you a lot of money and worry.

Back to Palliative Care vs. Hospice. According to Turn-Key (2018), non-medical personnel with PC can help with issues related to the serious illness such as “providing meals, transportation to and from doctor and other appointments, dealing with finances and payment of rent, mortgage, and other bills”. In addition, “specially trained professionals” and their services are typically offered at the beginning of the first PC treatment. Hospice care “includes physical care, counseling, drugs, equipment, and supplies for the terminal illness and related conditions”. Determination for hospice qualification relies on the certification from two physicians that the patient is terminally ill (has 6 months or less to live if illness runs its normal course) (CMS- Medicare Hospice Benefits Facts, 2018). Hospice agencies are paid on the level of care the patient receives each day, regardless of whether a service is provided to the patient or not on any particular day.

Palliative Care is appropriate at all disease stages and for any age patient regardless of whether the person is expected to fully recover or have continued disease progression. The focus is on the symptoms of the patient. Turn-Key (2018) states that fewer trips are made to the emergency departments, there are fewer hospitalizations, and patients spend less time in intensive care units in the last six months of life when palliative care is provided.

The issue with PC is that there is no specific reimbursement code for it, and many PC programs struggle financially. Hospital-based PC is paid primarily by the health system, and physician and nurse practitioner fees are covered by Medicare Part B for inpatient or outpatient care. PC is also paid through bundled payments under Medicare Advantage, Managed Medicaid, and ACOs (Accountable Care Organizations). ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients. (CMS May 3, 2018). Hospital teams are included within Medicare Part A or commercial insurance to hospitals. According to Turn-Key, “many thought leaders regard palliative care as a key to the future of healthcare.”

Source:

Palliative care and hospice: Understanding the differences part 1. Turn Key Health, 2018. Retrieved May 8, 2018 from https://turn-keyhealth.com/understanding-the-differences-of-palliative-care-and-hospice.