NHPCO Comments on June MedPAC Report to Congress

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The National Hospice and Palliative Care Organization offers comments on the Medicare Payment Advisory Commission’s (MedPAC’s) June Report to Congress that contains a review of issues that the Commission has highlighted about the hospice community and the services that are delivered to more than 1.65 million patients and families each year.

Extra care should be undertaken to ensure that any suggested changes to the Medicare Hospice Benefit must be measured and exclusively informed by validated data.

NHPCO offers the following comments in response to the new MedPAC report to Congress.

Short Lengths of Stay

NHPCO applauds MedPAC for the focus on the distressing fact that more than half of all hospice patients and their families receive this high quality end-of-life care for less than three weeks. Several of the MedPAC Commissioners have highlighted the fact that far too many hospice patients and their families (the hospice “unit” of care) are not receiving the full benefit of hospice services when they are referred too late in their disease trajectory. This issue has plagued patients and families for years and the new focus by MedPAC on this perennial problem is a welcome and necessary area of concern. At the heart of this issue is honoring patient wishes and giving patients and families the opportunity to consider and express their wishes throughout the health care system. The need for Medicare’s involvement in addressing this issue is unquestionable. We hope to see MedPAC give this issue attention it merits.

Hospice Payment Reform

The June Report to Congress continues to focus on the rationale for a possible new payment methodology for the hospice community and suggests, in previous presentations, based on partial data, a new approach to payment for hospice services. As the hospice community has long maintained, any payment reform proposal should be based upon comprehensive, validated and representative data elements. The hospice community has functioned, by almost all criteria, in accordance with fiscal responsibility, accountability and transparency (with average margins in the single digits). We support the approach being taken by The Centers for Medicare and Medicaid Services (CMS), which is consulting with various stakeholders and moving in a measured and responsible manner toward a new payment model.

Hospice Delivered in the Nursing Home Setting

The report points to a 2011 Office of the Inspector General (OIG) recommendation that hospice services delivered to nursing home residents should have a reduced payment rate What seems to be missing from this discussion is regard for the unique nature of end-of-life care in the nursing home setting. The limited analysis publicly shared by the Commission seems to rely heavily on one factor, the higher level of utilization of hospice aide services, to serve as the foundation of their recommendation. The report does not acknowledge that the vast majority of hospices already absorb a five percent rate reduction on dually eligible patients receiving hospice while residing in the nursing home, where Medicaid pays 95% of the nursing home’s room and board rate for the patient receiving hospice care. This significantly increases the challenges providers will have in serving those dying in this setting. Given that one out of four Americans is likely to die in a nursing home, we would have hoped that the conversation around this sensitive and complex issue deserves more robust and comprehensive discussion.

Live Discharges

In a section touching on live discharges, the report fails to make the necessary distinction between decisions made by patients and families to discontinue hospice care and instances where the hospice program discontinues services based on a change in the patient’s condition or other reasons. While the data collection illustrating these different types of discharges did not begin until mid-2012, the report relies on previous data that fails to acknowledge this important distinction. The use of the previous data confuses the issue by creating the impression that the numbers of live discharge decisions made by the hospice are larger.


In the June Report’s discussion of projected margins, the impact of sequestration (a 2 percent reduction in Medicare reimbursement) seems to be ignored. While other negative factors are mentioned (such as elimination of the BNAF, as well as cuts attributable to the ACA), the absence of the implementation of sequestration and its attendant payment reductions is troubling omission. When coupled with the complexity of the additional calculations necessary to more accurately reflect the hospice community’s “true” average margin, we remained concerned with the presentation of this particular information.

Final Comment

NHPCO recognizes and supports the need for all hospice programs to perform their roles utilizing the highest standards of care and an enduring commitment to high quality compassionate care for patients and families. There is an acknowledged desperation among policy makers to solve the nation’s fiscal issues and preserve Medicare for future generations. Given these myriad pressures, extra care should be undertaken to ensure that any suggested changes to the Medicare Hospice Benefit must be measured and exclusively informed by validated data. The hospice community stands ready to work with MedPAC and any responsible policy making body to improve the delivery and experience of end-of-life care in this country.

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Jon Radulovic
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