Referral to Hospice

Referral to Hospice

Eligibility

1. M.P. is an 89-year-old woman referred to hospice for end-stage Alzheimer's dementia (AD). She lives in a residential care home for the elderly with a hired caregiver. Her husband has been unable to care for her at home for some time because she requires full assistance with all activities of daily living. She was recently hospitalized with aspiration pneumonia and a urinary tract infection, and completed a course of intravenous vancomycin and Zosyn. Her past medical history includes osteoporosis, coronary artery disease, chronic obstructive pulmonary disease (COPD), hypercholesterolemia, and hypothyroidism. She is not oriented to person, place, or date. Her speech is unintelligible or nonsensical. She cannot feed herself, but will eat the thick pureed food that is fed to her. She is bed-bound and incontinent of urine and stool. She is agitated at times, especially at night. Her Palliative Performance Scale (PPS) is 30%. Weight is 112 lb, decreased from 135 lb a year ago, and a recent serum albumin is 2.2 g/dL. What criteria does M.P. meet for eligibility for hospice services under the Medicare Hospice Benefit?

Table 6-2 Drug Costs in Relation to Hospice Reimbursement (Routine Level of Care)

Year Unadjusted Daily Reimbursement15,20–26 % Annual Rate Increase Average Annual Price Increase for Most Widely Used Brand Name Drugs31–33 Hospice Per Diem Drug Costs30 Drug Costs as % of Reimbursement30 WAC AWP 1983 $46.25 NA     $1.06 2.3% 1999 $97.11 110%*     $2.48 2.5% 2000 $101.84 4.9% 4.1% 6.0 NA NA 2001 $101.84 0% 4.7% 6.0 $15.72 13.4% 2002 $110.42 8.4% 6.1% 6.0     2003 $114.20 3.4% 7.0% 6.0, 6.5     2004 $118.08 3.4% 7.1% 6.0     2005 $121.98 3.3% 6.0% (21.6%, 2001-2004)     2006 $126.49 3.7% 6.2%       2007 $130.79 3.4%         2008 $135.11 3.3%         WAC, wholesale acquisition cost (manufacturer's list price to wholesalers); AWP, average wholesale price (determined by manufacturer). *For a 16-year period.

Patients with chronic diseases (e.g., Alzheimer disease, Parkinson disease, stroke, heart failure, lung disease) can be sufficiently ill and debilitated to need custodial care, but might not be sufficiently ill to meet the definition of a terminal illness. This differentiation between terminally ill versus chronically ill requiring custodial care is important because in order to qualify for hospice services under the Medicare Hospice Benefit, patients must be at a stage where death is expected within the next 6 months. For cancer diagnoses, the presence of widespread metastatic disease may make this prognosis more easily evident. However, for other chronic diseases, this is not as clear.

The Medicare fiscal intermediaries have issued criteria to assist in the determination of eligibility for hospice care, as well as criteria to meet a 6-month terminal prognosis for a number of diseases. These criteria, or local coverage determinations (LCDs), provide guidelines for meeting an overall decline in clinical status, for meeting non-disease-specific data to establish a baseline, for establishing the effect of comorbidities (e.g., renal failure, liver disease), and for the submission of documentation for having met criteria. Criteria have been established for patients with cancer and noncancer diagnoses, and these criteria are used in the determination of eligibility for service and reimbursement.^14,34 Criteria for the noncancer diagnoses have been developed for amyotrophic lateral sclerosis, dementia due to Alzheimer's disease and related disorders, heart disease, HIV disease, liver disease, pulmonary disease, stroke, coma of any etiology, and acute and chronic renal disease.

The determination of whether M.P. meets eligibility requirements for Medicare Hospice Benefits must be based on the established LCDs for dementia due to Alzheimer's disease. These criteria are as follows:

• Stage 7 or beyond, according to the Functional Assessment Staging Scale
  • Stage 7A: Can speak six or fewer intelligible words in a day or during an interview
  • Stage 7B: Speech ability limited to the use of a single intelligible word in a day or during an interview
  • Stage 7C: Cannot ambulate without assistance
  • Stage 7D: Cannot sit up without assistance
  • Stage 7E: Loss of ability to smile
  • Stage 7F: Loss of ability to hold head up independently
• Unable to ambulate without assistance
• Unable to dress without assistance
• Unable to bathe without assistance
• Urinary and fecal incontinence, intermittent or constant
• No consistently meaningful verbal communication; stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words
• One of the following within the past 12 months: aspiration pneumonia; pyelonephritis or upper urinary tract infection, septicemia, decubitus ulcers (multiple, stages 3 and 4), fever (recurrent after antibiotic treatment)
• Inability to maintain sufficient fluid and caloric intake with 10% weight loss during the previous 6 months or serum albumin <2.5 g/dL

The PPS score (Table 6-3) gradates the extent of disability and can be used to assist in the determination of hospice eligibility.³⁵ M.P. meets the previous criteria and is eligible for hospice because of her Alzheimer disease. She clearly is debilitated. She is unable to speak intelligently, cannot feed herself, is not oriented to time or place, incontinent of urine and stool, has lost about 20% of her weight during the past year, has a serum albumin of 2.2 g/dL, and has a PPS rating of 30% (i.e., totally bed-bound, unable to do any activity, confused). In addition, she has a number of comorbidities, experienced a recent episode of aspiration pneumonia, and finished a course of antibiotic therapy.

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Table 6-3 Palliative Performance Score (PPSv2) version 2

PPS Level Ambulation Activity and Evidence of Disease Self-Care Intake Conscious Level 100% Full Normal activity and work No evidence of disease Full Normal Full 90% Full Normal activity and work Some evidence of disease Full Normal Full 80% Full Normal activity with effort Some evidence of disease Full Normal or reduced Full 70% Reduced Unable to do normal job/work Significant disease Full Normal or reduced Full 60% Reduced Unable to do hobby/house work Significant disease Occasional assistance necessary Normal or reduced Full or Confusion 50% Mainly sit/lie Unable to do any work Extensive disease Considerable assistance required Normal or reduced Full or confusion 40% Mainly in bed Unable to do most activity Extensive disease Mainly assistance Normal or reduced Full or drowsy ± confusion 30% Totally bed-bound Unable to do any activity Extensive disease Total care Normal or reduced Full or drowsy ± confusion 20% Totally bed-bound Unable to do any activity Extensive disease Total care Minimal to sips Full or drowsy ± confusion 10% Totally bed-bound Unable to do any activity Extensive disease Total care Mouth care only Drowsy or coma ± confusion 0% Death ¾ ¾ ¾ ¾ From reference 35; adapted with permission of the Victoria Hospice Society.

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