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02/12/2010

Hospice E-News Volume 15, Issue 6 February 12, 2010

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PATIENTS' UNDERSTANDING OF ILLNESS INFORMS THEIR CHOICES ABOUT TREATMENT

According to "Choices at the End of Life" in The Los Angeles Times, end of life is a time that can be emotionally and financially draining. Those who've studied the matter say that informed choice can make a difference. (The Los Angeles Times, 1/25)
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ARTICLE EXAMINES DECISIONS RELATED TO WITHHOLDING INFORMATION FROM PATIENTS

"Withholding Information From Patients: When Less is More," in the current NEJM, examines the circumstances in which physicians consciously or unconsciously hold back information from patients about "their conditions, treatments, and outcomes." Authors Ronald M. Epstein, MD, David N. Korones, M., and Timothy E. Quill, MD, say that the principle of autonomy suggests that "patients should always be fully informed, not only so that they can make the best possible decisions, but also because information helps them to make sense of and cope with illness." That information, however, sometimes increases the "cognitive and emotional burden" on the patient, and leads to "greater confusion rather than clarity." Therefore, they say, "The right to autonomy must be balanced with the ethical obligations to do good for patients (beneficence) and not to harm them (nonmaleficence)." The article briefly cites that the clear cases for withholding information include when the patient is not competent so the information is given to a surrogate, medical treatment is so urgently needed there is not time to explain, or the patient chooses not to know, so again the surrogate is informed.

When the cases fall into a "gray zone ... choices about providing or withholding information should be made in such a way as to maximize benefit and minimize psychological and cognitive and emotional burdens." The article suggests that physicians weigh instrumental benefits (help in decision-making, or in obtaining resources), and emotional and relational benefits. Consideration of the burdens of information is "more complex." When patients and family are under stress, too much information "may impair rather than facilitate understanding and decision making." For instance, listing all possible, but improbable, side effects of a treatment can distract both patient and physician and "obscure more relevant information." Discussion of a benign incidental finding, such as a cyst unrelated to the patient's terminal illness, "can derail exploration of the complexities of a serious illness and the relevant treatment options."

The authors add, "Providing every detail of clinical information also takes time and may crowd out more important discussions.  Time taken to explain to a hospice patient that she now has five rather than three pulmonary metastases might be better used to discuss how to relieve her symptoms or how her family is coping."  Clinicians should determine whether information will "enhance or reduce patients' autonomy." "Patients' ability to acquire and use information and fully participate in their care does not depend solely on how much information they receive -it also depends on the nature of their relationships with their clinicians, their families, and others. If patients distrust their physicians, they tend to seek more information. If patients are left alone to sort out complex information, they may feel abandoned and less able to exercise control. The ideal goal may be ‘autonomy-in-relation,' which entails collaboration among patients, their loved ones, and clinicians in seeking, interpreting, contextualizing, and acting on information."

The authors caution physicians against bias, conscious or unconscious, in judging whether to withhold clinical information.  Pressures of time and financial incentives may discourage conversations about treatments. If patients or families are potentially contentious, physicians may omit mentioning some "controversial aspects of care." Clinician decisions about providing information require "self-awareness and honesty." In conclusion, the authors say, "We propose some simple rules: If the patient asks, the clinician should tell. If the clinician is anxious about what would happen if a patient discovers that information has been withheld, then the decision to withhold should be reconsidered. Clinicians should scrutinize their tacit judgments by routinely asking themselves questions such as ‘What would a trusted peer say?' ‘Am I feeling uncomfortable?' or ‘Am I assuming that the patient's values are the same as mine?' Clinicians should overcome potential biases by getting to know each patient as an individual. And, when uncertain, clinicians should discuss the decision to withhold information with a trusted member of the patient's inner circle, experienced colleagues, or both." (NEJM, 2010;362:380-381)
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RESEARCH & RESOURCE NOTES

  • A study from the University of Colorado has found that "informal caregivers of hospice patients have support needs that are amenable to telephone-based counseling designed to be complementary to existing hospice services." A pilot program has been established to test a "telephone-based cognitive-behavioral stress management program for informal caregivers." A "pervasive theme" of the study of 36 caregivers and 11 hospice staff members was that "there can never be enough support for a caregiver." (Journal of Palliative Medicine, 2010;12(12):1101-1104)
  • The free full text of "Willful Modulation of Brain Activity in Disorders of Consciousness" is online at New England Journal of Medicine. (NEJM, 2010)

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PUBLIC POLICY NOTES

  • In an editorial, The News York Times says the failure of the legislature to pass the Family Health Care Decisions Act, which would allow family members to make decisions for loved ones who are incapacitated, is "a concrete measure of how New Yorkers are hurt by Albany's chronic dysfunction." (The New York Times, 2/4)
  • The Arizona legislature has cut some care options for some patients with terminal illnesses, and hospices may have to repay the state for service already provided. To read the article, click here. (Arizona Daily Star, 2/1)

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HOSPICE & PALLIATIVE CARE NOTEs

  • As the Institute for Palliative Medicine at San Diego Hospice marked its 20th anniversary recently, one of its physicians, Jeff Stoneberg, received the first ever Hastings Center Cunniff-Dixon Physician Award. Stoneberg was recognized "for bringing some fundamentals of hospice care ... to a hospital that seeks to cure people." (KPBS Website, 2/1)
  • An article in the Journal of Palliative Medicine discussed addresses palliative care referral practices of nurses. (Journal of Palliative Medicine, 2009;12(12):1131-1136; The Institute of Child Health Policy Website)
  • The founder of one of the first children's palliative care programs in the US, Dr. Burton Grebin, has died. The Wall Street Journal article says Dr. Grebin "transformed a 40-bed children's hospital in Queens, N.Y., into one of the largest providers of care for special-needs pediatric patients, including those with AIDS, head traumas and eating disorders." (The Wall Street Journal, 2/4)

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OTHER NOTES

  • The FDA has approved morphine sulfate for oral administration for the relief of acute and chronic pain. The drug is available in a 20 mg/ml concentration. The press release says that, although this medication has commonly been used orally for pain, this concentration and form of morphine sulfate has only now been approved by the FDA. (FDA Press Announcement, 1/26)
  • Making Rounds With Oscar: The Extraordinary Gift of an Ordinary Cat, by Dr. David Dosa, has been released. Oscar, whose ability to identify dying nursing home patients was chronicled in a NEJM article, is "important to family members and caregivers who have been with him at the end of a life," Dosa said. Dosa adds that he never meant to make Oscar "sound creepy," and hopes the book "will put the cat in a more favorable light as well as providing a book to help people whose loved ones are terminally ill." (Yahoo! News, 2/2)
  • Colorado coroners say the burgeoning green movement may mean that more people will be buried at home. They want the state to start tracking where people are buried. They're trying to forestall future problems, when new owners of a residential property dig up a body in the back yard, necessitating an investigation into whether foul play occurred. The Colorodao Coroners Association says it isn't trying to discourage such burials, only that they "want to know where you are if you aren't in a graveyard." (Vail Daily, 2/3)
  • "The Year Ahead," in The Hospitalist, cites Nancy Berlinger, deputy director of The Hastings Center, as saying that end-of-life issues will be prominent for hospitalists this year. (The Hospitalist, 2/2010)

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STATE NEWS

ODJFS Payment Processing Error
A processing error has occurred with the Medicaid provider payments scheduled for Thursday, February 11, 2010.  Payments are expected to be available on Tuesday, February 16, 2010, given that Monday is a holiday. (Rosemary Walton, ODJFS, 2/10/10)

Arizona Patients Lose Hospice Care
The Yuma Sun article, "State Cuts Hospice Care" addresses the Medicaid cuts that occurred in December 2009. (Wilken, 2/11).   (Kaiser Health News, 2/12/10)

Akron Health Department & Summit County Health District to Merge
A merger feasibility study committee unanimously approved a report this week that recommends the merging of the Akron Health Department and the Summit County Health District. To read the article, click here. (Ohio Health Policy Review, 02/12/2010)
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OHPCO COMPLIANCE AND REGULATORY UPDATES

New Transmittal Changes Edits for Claims After 7/6/10
CMS issued Transmittal 1011, CR6778, with claims system edits for hospice claims. Edits will be installed for claims submitted July 6, 2010 or later. The edits will do the following:

  • Allow Medicare Advantage plans to get paid for the day of election for patients who elect the Medicare hospice benefit. On or after July 6, 2010, the Common Working File (CWF) will allow claims to be processed for both the Medicare Advantage plan and Medicare hospice for services occurring on the date of the hospice election. This will prevent services provided on the date of the election from rejecting as MA Plan responsibility. Providers that have claims being disputed may resubmit their claims on or after July 6, 2010 to the appropriate FFS Medicare contractor for payment consideration. Contractors will not be required to provide automated adjustments.
  • Ensures the proper site of service for GIP, Respite and Continuous Care and "returns to provider" those claims with an improper site of service. CMS is implementing several edits within the claims processing system to ensure that hospice days are billed at the appropriate setting.
  • Clarifies the role of nursing care in continuous home care. The change reads: "Nursing care must be provided for more than half of the period of care...." CMS has made this "technical" correction to the manual, Publication 100-04, Section 30.1.  This appears to be more than a technical correction, but a complete change to long standing hospice interpretation policy. The related MedLearn article, MM6778 -  Medicare Systems Edit Refinements Related to Hospice Services, is located HERE. Further clarification has been requested from CMS. 

Counting Patients for the 2010 Census
NHPCO has received emails and calls from providers about how to count patients in hospice facilities for the 2010 Census. There is guidance that has been released for patients in nursing homes and in the hospital. NHPCO has asked legal counsel to do some additional research about the question. When an answer is available providers will be notified.  

HIPAA Business Associate Agreement
As of February 17, 2010, all covered entities must ensure compliance with HITECH and that ePHI remains private and secure and business associate agreements must be updated to include additional requirements for breach notification. Watch for an upcoming NHPCO Regulatory Alert and HITECH rule summary offering guidance for hospice providers. (NHPCO, 2/11/10)
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CMS AND FEDERAL NEWS AND CHANGES

New NPI Booklet Available
The NPI Booklet is Now Available for Download! The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard, unique health identifier for each health care provider. The NPI Final Rule, originally published on January 23, 2004, established the NPI as this standard. Covered entities under HIPAA are required by regulation to use NPIs to identify health care providers in HIPAA standard transactions. (CMS, 2/9/10)

Feeding Tube with Advanced Dementia Use More Likely at Big, For-Profit Hospitals
To read the Business Week article, click here. (Kaiser Health News, 2/10/10)

Point of Origin for Admission or Visit Codes Update to the UB-04
CMS released Transmittal 1917, on February 5, 2010, Change Request 6801on the following Point of Origin for Admission or Visit (formerly Source of Admission) codes, discontinued by the National Uniform Billing Committee (NUBC), will be discontinued for use by the Fiscal Intermediary Standard System (FISS): 7-Discontinued Effective July 1, 2010, B-Discontinued Effective July 1, 2010, C-Discontinued Effective July 1, 2010.

To read the related MedLearn article, MM6801 - Point of Origin for Admission or Visit Codes Update to the UB-04 (CMS-1450) Manual Code List, click here. The CR is effective 7/6/10. (CMS, 2/12/10)

ZPICS Are Active In Eastern US
A hospice Director from MA reported that last week, I didn't know what a ZPIC was and now we have our first notice from a member that they have contacted them for contract and employee information. He member was contacted by SafeguardServices  a ZPIC or Zone Program Integrity Contractor for Part A in most eastern states, including Massachusetts. They are "dedicated to program integrity through enhanced data analysis capabilities." The mission of Safeguard Services is to help address fraud, waste and abuse by performing regional Medicare data analysis as well as comprehensive problem identification and research to identify potentially fraudulent Medicare providers. Their web site is www.edssafeguardservices.eds-gov.com.

NOTE OHPCO: The Program Safeguard Contractors graduated and became the ZPICS. (Hospice & Palliative Care Federation of MA, 2/12/10)
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PALMETTO GBA UPDATES AND CHANGES

Healthcare Provider Taxonomy Codes (HPTC): April 1, 2010 Update
CMS released the summary of changes reflected in the Health Care Provider Taxonomy Code (HPTC) list, effective on April 1, 2010. (PGBA, 2/10/10)

January 21, 2010, Ask-the-Contractor Teleconference (ACT) Meeting Minutes
The January 21, 2010, Ask-the-Contractor Teleconference (ACT) minutes are now available. (PGBA, 2/10/10)

Providers Legally Eligible to Order and Refer Patients for Treatment Under Medicare Program
CMS has made a file available that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS). To access this file, click here. (PGBA, 2/11/10)

Palmetto GBA Hospice Coalition Meeting Questions December 2009
The December Hospice Coalition Meeting questions and answers are now available. To access the Q & As, click here. (PGBA, 2/12/10)

Correction to Processing of Non-Covered Revenue Codes
This MedLearn article, based on CR6774, explains that claims containing an institutional service line submitted with a revenue code that is not valid for Medicare billing will only be returned to the provider if the line is submitted with covered charges or the claim indicates that beneficiary liability may apply. Affected providers should ensure that their billing staffs are aware of these changes that are effective for claims processed on or after July 6, 2010. To read Transmittal 1900, dated 1/29/10, click here. This becomes effective on 7/1/10. To read the related MedLearn article, MM6736 - Instructions on How to Process Negative Claim Adjustment Reason Code (CARC) Adjustment Amounts when Certain CARCs Appear on Medicare Secondary Payer Claims, click here. (CMS, 1/29/10)
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WEATHERBEE THOUGHTS ON RAC HOSPICE RELATED AUDITS

Click here to read the complete Weatherbee article. (Weatherbee, 1/28/10)
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Thanks to Kathy McMahon for contributions. Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2010.  Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division.  Ask your insurance agent to visit their website at www.hccis.com.  Hospice News Network is published 45-47 times a year by a consortium of state hospice organizations.  Copyright, 2010.  All rights reserved to HNN subscribers, who may distribute HNN, in whole or part, to provider members of the subscribers' state organizations.  If readers need further information, they should consult the original source or call their state association office.  HNN exists to provide summaries of local, state and national news coverage of issues that are of interest to hospice leaders.  HNN disclaims all liability for validity of the information.  The information in HNN is compiled from numerous sources and people who access information from HNN should also research original sources.  The information in HNN is not exhaustive and HNN makes no warranty as to the reliability, accuracy, timeliness, usefulness or completeness of the information.  HNN does not and cannot research the communications and materials shared and is not responsible for the content.  If any reader feels that the original source is not accurate, HNN welcomes letters to the editor that may be shared with HNN readers. The views and opinions expressed by HNN articles and notes are not intended to and do not necessarily reflect views and opinions of HNN, the editor, or contributors.  Only subscribing state hospice organizations have rights to distribute HNN and all subscribers understand and agree to the terms stated here. (Volume 14, Number 6, February 9, 2010)


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