The Value Proposition of Hospice Transfers under Medicare Reimbursement

“Medicare coverage of hospice depends on a physician’s certification that an individual’s prognosis is a life expectancy of six months or less if the terminal illness runs its normal course.”

This is the criteria set by Medicare for admitting a patient into hospice. CMS provides several documents that provide guidelines for determining if patients qualify based on their clinical situation and this definition. These documents state that this is an inexact science and that it is understood that some patients will last longer and that some clinical issues and indicators are much harder to use for predictions than others. For example, weight loss is a very good indicator, loss of cognitive function is not. These documents also describe how patients can be discharged by a hospice if the clinical data changes to the point where their remaining lifetime is expected to exceed this six month guideline.

Budgeted Hospice Caps

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Preparing for the Transition to Value-Based Payments

One thing I have learned over my 30 years in healthcare IT is that our industry will fight against change with its last breath, regardless of the logic or benefits of any new process that might be under consideration. ICD10 is the most recent example. It is simply a technical change in how one data element in healthcare patient information is recorded and processed.

Despite how it may impact the industry financially due to implementation costs and delays, it is a significant improvement in the quality of clinical data collected and a necessary step in the evolution of healthcare IT systems. The clinical and financial decisions that depend on the accuracy of diagnoses will benefit from the ability to establish new relationships regarding the effectiveness and cost benefits of different treatments plans. Once this new code set is established, new insights will be gained through this data that would not have been possible with the more general ICD9 codes.

Value-Based Payments

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