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03/03/2010

Hospice E-News Volume 15, Issue 9 March 4, 2010

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STUDY ADDRESSES IMPACT OF PEDIATRIC PALLIATIVE CARE ON FAMILIES

"Family Support in Pediatric Palliative Care: How Are Families Impacted by their Children's Illnesses?," in the February 9 Journal of Palliative Medicine, reports on a Florida study of children and families enrolled in the state's publicly funded palliative care program, Partners in Care: Together for Kids (PIC:TFK). The Impact on Family (IOF) Scale was used to measure outcomes, together with the PedsQL Generic Version 4.0 to control for quality of life issues, and the Center for Epidemiologic Studies Depression scale to control for parental depression. All the children, who were between the ages of one and twenty-one, were diagnosed with life-limiting illnesses. Children enrolled in the PIC:TFK program are also eligible for public insurance (Medicaid, State Children's Health Insurance Program, etc).

Most families were white (56%), English-speaking (80%), married (54%), had attended or graduated college (63%), were in two-parent households (60%), and included other children in the household (62%). The average age of the parents was 41 years, the average age of the children was 8.6. Almost half the parents (48%) had depressive symptoms on the depression scale. The survey of parents used the 15-item IOF scale, which was reduced from 27 items after a 2003 validation study. The percentage of those responding parents who agreed with the items is as follows:

  • Ninety percent feel like they sometimes live on a rollercoaster.
  • Seventy-seven percent find it hard to find a reliable caregiver/sitter.
  • Seventy-six report making last minute changes in plans because of the child.
  • Seventy-one percent report making family sacrifices because of the illness.
  • Seventy-one percent report problems with fatigue.
  • Sixty-four percent caring for the child means not having much time left for other family members.
  • Sixty-one percent report being unable to travel because of the illness.
  • Sixty percent say that traveling to the hospital is a "strain."
  • Fifty-seven percent sometimes wonder if the child should get "special" treatment.
  • Fifty-five percent feel that no one understands their problems.
  • Fifty-four percent report that they see less of family and friends because of the illness.
  • Forty-eight percent think about not having additional children because of the illness.
  • Forty-eight percent don't plan for the future and live from day to day.
  • Forty-four percent report little desire to go out because of the illness.
  • Forty-three percent that they receive special treatment from their neighbors because of the illness.

The authors suggest a number of services that could be offered to assist parents, such as support groups and transportation services. They also say that 22% of the respondents sometimes used respite care, though that was not one of the items on the survey. "If pediatric palliative care programs are unable to offer services that are important to families," the article says, "staff should act as a conduit to try and locate other community resources that might be available." The authors note several limitations of the study. The response rate was only 45%, which may indicate "inherent differences between responders and nonresponders." An earlier study of families with children with life-limiting illnesses found differences in responses by race and stage of the child's illness.  Medicaid families, by definition, have low incomes, and the article cites studies showing that Medicaid-eligible children "tend to have lower health outcomes." The study did not indicate whether the respondent was the mother or the father. The effect of depression on the family was estimated, and other factors (e.g., PTSD, stress, anxiety, etc) were not controlled for. Last, these children were receiving palliative care from a hospice, and results might be different in another institution.

In spite of the limitations, the authors say that the study contributes to the literature on this issue, and "is the first to provide evidence on the factors that are associated with impact on family within a population of parents whose children who are eligible for pediatric palliative care. The ability to measure the impact of children's illnesses on their families in an easy, valid, and reliable manner, as well as comment on the factors that are associated with greater impact on families, should provide the pediatric palliative care community with another tool that can be used to screen families for psychosocial needs and address those needs with the appropriate services." (Journal of Palliative Medicine, 2010; 2/9)
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RELUCTANCE TO PRESCRIBE OPIOIDS

"Are Doctors Too Reluctant to Prescribe Opioids?" in the current Time, looks at the difference between addiction and dependence, the current patterns of prescription of pain medications, and the problems involved in treating pain. Click here to read the full article.
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PUBLIC POLICY NOTES

  • As Vietnam veterans age, the number of deaths in that group has nearly doubled since 2001. The Department of Veterans Affairs projects that this year the number will rise to 300 per day, more than five times the daily average of soldier deaths during the actual combat. Click here to read the full article. (Cleveland.com, 2/7)
  • The Montana Supreme Court recently upheld the right of physicians to prescribe life-ending medication for certain patients, and Dr. Stephen Speckart, a Missoula cancer specialist, "hopes to build awareness of how the Supreme Court's decision impacts Montana doctors." Click here to read the full article. (Missoula Independent, 2/25)

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HOSPICE & PALLIATIVE CARE NOTES

  • In Iowa, Hospice With Heart is offering a program, "It's How You Live at Work," that is attracting the interest of employers.  The program, which received grants from NHPCO and the Pottawatamie County Community Foundation, is "designed to help employers help employees dealing with end-of-life, grief and caregiving issues." Click here to read the full article. (Southwest Iowa News, 2/21)
  • On its 25th anniversary, the Hospice of Wichita Falls took steps to diversify its outreach to patients.  The Hospice brought in Elaine Magruder, who was part of a volunteer group that organized hospice services in Vietnam. Click here to read the full article. (The TimesRecord News, 2/24 )
  • The California Healthcare Foundation has published a new online report, "Creating a Palliative Care Program: Insights From Hospital Leaders." The Foundation interviewed medical and administrative leaders about various palliative care programs, asking for information on how they were set up, the benefits and challenges of the programs, and relationships with clinical staff.  Reported benefits include "cost-savings, improved patient and staff satisfaction, and enhanced reputation," greater efficiency for physicians because palliative care staff pick up more interactions with the patients and families, and individualized care for patients. (California HealthCare Foundation, 2/2010)
  • An MSNBC article says that Americans often confuse hospice and palliative care. The article briefly explains the differences, and gives suggestions on calling in a palliative care specialist when one is needed. (MSNBC Website, 2/26)

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OTHER NOTES

  • "Social Work Role in Hospice Pain Management" reports on a study of social workers role in hospice pain management, especially regarding concerns of caregivers about pain management. The data "suggested that while social workers may understand their role in pain management they struggled for the time and tools needed to help address caregiver concerns related to pain management." The researchers suggested the development of standardized assessment tools for social workers, and called for research on social worker-caregiver interactions related to pain. (Journal of Social Work in End-of-Life & Palliative Care, 2010;5(1&2):61-74)).
  • When Pam Sakuda's cancer metastasized, she participated in a pilot study that combined talk therapy with a dose of psilocybin, hoping to ease her fears of death. Psilocybin is the active ingredient in psychedelic mushrooms, and the FDA has approved it for use in "pilot clinical trials to treat end-of-life distress." In the study, Sakuda's therapist, psychiatrist Charles Grob, found "reduced anxiety and improved mood and quality of life, and an indication that these benefits were sustained over several months." Researchers at Johns Hopkins University and New York University are planning similar studies, hoping to expand on Grob's work. (Scienceline Website, 2/24)
  • The Rev. Dr. Walter Smith, CEO of HealthCare Chaplaincy, says that there are fewer good deaths than bad ones. One of the problems is that living wills are often ignored, and Dr. Terri Fried, of the Veterans Affairs Connecticut Health System, says that they ask the wrong questions. Fried says it would be better to ask how people want to live, or "under what conditions they would not want to live," rather than specifying what interventions they might or might not want. (MSNBC Website, 2/26 )
  • On his "Special Comment" on health care on MSNBC last week, Keith Olbermann told the story of his father's hospitalization, six months in length, as he suffered pneumonia, kidney and liver failure, pneumonia, and multiple infections. His father, panicky, begged Olbermann to kill him. Click here to read the article and watch the video. (Huffington Post Website, 2/24)

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NHPCO COMPLIANCE AND REGULATORY UPDATES

Clarification of Ambulance Transports on the Day of Hospice Admission
In addition to CR 6778 proving clarification about payment of ambulance transports on the effective date of hospice election, CMS has also updated Medicare Benefit Policy Manual (CMS Pub. 100-02) with additional information. CMS has defined the circumstances when the hospice provider is responsible for the cost of ambulance transport.

Hospice responsible: Ambulance transports of a hospice patient, which are related to the terminal diagnosis and which occur after the effective date of election, are the responsibility of the hospice.

Hospice not responsible: Ambulance transports which occur on the effective date of the hospice election (i.e., the date of admission), but prior to the initial assessment and prior to the plan of care's development. (Per the S & C 09-19, Advance Copy-Hospice Program Interpretive Guidance Version 1.1, the initial assessment must be conducted in the location where hospice services will be provided, and the plan of care is developed from that initial assessment and from the comprehensive assessment.)  Implementation date: For claims submitted on or after July 6, 2010

(NHPCO, 2/26/10)

If Your Hospice Experiences Drug Shortages
Roxane Laboratories recently received approval from the FDA for morphine sulfate 100mg/5 ml (20mg/ml) oral solution; Roxane is now the only FDA approved manufacturer of morphine sulfate oral solution. Roxane reports that they are now able to cover all patient needs with their current inventory and production. FDA's Drug Shortage Program monitors the US monthly demand using market sales data resources and Roxane has built up inventory sufficient to cover the total market demand for 5 months and their reported ongoing production is more than sufficient to cover all US demand. Roxane reports they will continue to have inventory and production that will meet all patient needs.  Roxane has agreed to address any access issues immediately. Roxane's morphine sulfate information is posted in the Resolved Shortages section of the FDA Drug Shortage website or you may call Roxane's customer service at 1-800-520-1631. Roxane will help anyone having any difficulty finding the approved product through wholesalers or pharmacies and will also provide product through direct order.

Contains the current NDC numbers that can be used to order Roxane's morphine oral solution 100mg per 5ml (20mg/ml). There will be a transition period to the new packaging, labeling, and NDC numbers. In the meantime, please continue to use the following NDC numbers: NDC 0054-0352-44 Morphine Sulfate Oral Solution CII, 20mg/mL 30mL Bottle. NDC 0054-0352-50 Morphine Sulfate Oral Solution CII, 20mg/mL 120mL Bottle. FDA wants to continue to ensure that morphine sulfate 100mg/5 ml (20mg/ml) oral solution is available to meet patient needs and would like to be contacted if anyone has any questions or concerns about morphine sulfate or any other product's availability.  The FDA Drug Shortage Program is glad to help and can be reached at drugshortages@fda.hhs.gov.  (NHPCO, 2/25/10) 

CR6440:  Social Worker Calls Q&A Update
CMS posted a Q&A update related to the Social Worker phone call requirement in CR 6440. The language in the new Q&A states that CMS acknowledges that care coordination phone calls by social workers to people and organizations in addition to family members could be reportable on the claim form. This is a change from the January 27, 2010 CMS Q&A posting which stated that only calls to the patient and family should be recorded on the claim form. (NHPCO, 2/25/10) 

Have You Hugged Your Social Worker Today?
March is national Social Worker's Month. Now is the time to show recognition for their dedication and hard work! NHPCO's Marketplace has plenty of gift ideas to show your support; Go to marketplace@nhpco.org. (NHPCO, 2/26/10)

Hospices Send Your Data to Ensure Adequate Payment
NHPCO has retained The Moran Company, a Washington-based healthcare research and consulting firm, to collect the most recently available patient-level hospice data in order to model potential alternative payment systems. These models will inform NHPCO's discussions with MedPAC and CMS regarding future hospice payment reform strategies and improvements in documentation.

Through the contract, The Moran Company is working closely with hospice software vendors who have agreed to participate, including Allscripts, Cerner BeyondNow, Consolo Services, Mumms, and Suncoast Solutions. Each hospice will receive specific instructions based on which software vendor it uses. All data will be sent directly to The Moran Company; NHPCO will not see any hospice-specific data, and hospices who wish to remain anonymous may do so by confidentially donating their data. Also, the specifics of these data will not be released to any government agency -- only aggregated results will be included in reports.

Your participation is critical to the success of this project, and NHPCO's ability to proactively recommend payment strategies to CMS. If you are interested, contact your software vendor or Amanda Forys at The Moran Company at aaforys@themorancompany.com. For more information about The Moran Company visit their website. NHPCO has created a landing page on the NHPCO website that includes a letter from Don Schumacher to the hospice community; more information about the Moran project will be added as it becomes available. Visit this page at nhpco.org/moran. (NHPCO, 2/25/10)
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CMS AND FEDERAL NEWS

CMS Home Health, Hospice & DME Open Door Forum
CMS Home Health, Hospice & DME Open Door Forum is scheduled for Wednesday, March 10, 2010 at 2:00 PM Eastern Time (ET). Please dial-in at least 15 minutes prior to call start time. The conference leaders are: Lori Anderson, Nancy O'Connor, and  Natalie Highsmith. To participate by phone the Dial: 1-800-837-1935 and the Reference Conference ID: is 49632727. Registration for phone participation is not required. The encore  audio recording that can be accessed by dialing 1-800-642-1687 and entering the Conference ID, beginning 2 hours after the call ends and will expire after 3 business days. (CMS, 2/24/10)

Government Control of Health Care Key Focus at Summit
For those familiar with the typical contentiousness and friction in congressional debate on health care reform over the last year, the health care reform summit convened by President Barack Obama proved perhaps as civil and frank a discussion on the issue as any to date. To read the detailed article, click here. (NAHC, 2/26/10)

Extension of Additional Medicaid Assistance Needed Say Governors
42 state governors and governors of five U.S. territories signed their names to a letter asking congressional leaders to extend the currently enhanced federal Medicaid matching funds for another two quarters. To read the article and to access the Governors' letter, click here. (NAHC, 2/23/10)

Revised Medicare Appeal Process Brochure
The revised Medicare Appeals Process brochure (January 2010), which provides an overview of the Medicare Part A and Part B administrative appeals process available to providers, physicians and other suppliers who provide services and supplies to Medicare beneficiaries, as well as details on where to obtain more information about this appeals process, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network. (CMS, 2/22/10)
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STATE NEWS

Governor Signs Bill Extending COBRA Health Care Coverage
Ohio Governor Ted Strickland signed House Bill 300, extending Ohio continuation (mini-COBRA) coverage from 12 months to 15 months so Ohioans who lose their jobs are able take full advantage of the federal subsidies available to help pay for the cost of mini-COBRA. The bill, sponsored by Representatives Stephen Dyer and Jay Hottinger also brings Ohio into uniformity with the National Association of Insurance Commissioners (NAIC) standards adopted by 46 other states related to insurance agent licensing and oversight. Changes to agent license standards include:

  • A mandatory federal background check for licensure.
  • 24 hours of Continuing Education, including three hours of ethics education, will be required for all major lines of authority.
  • The collection of licensure fees after applicant has passed exam instead of before.
  • The inactivation of an agent license if the agent does not apply for renewal and meet the requirements by the end of the renewal period or 30-day late filing period.
  • Waiving of pre-license education requirements if an individual applicant has earned a professional designation approved by the superintendent. 

"This law will enhance Ohio's insurance licensing standards, while at the same time, increasing consumer protection for Ohioans who purchase insurance products," said Director Hudson. "The mini-COBRA changes will also temporarily allow those who lose their job to maintain their health insurance for a little while longer." The complete version of HB 300 can be found on the Ohio Department of Insurance Web site, www.insurance.ohio.gov. Ohioans with questions about the new law can call the Department's consumer hotline at 1-800-686-1526. (ODI, 2/26/10)

CMS Sends Letter to ODJFS Director
CMS issued a State Medicaid Director (SMD) letter that provides guidance on the implementation of certain provisions of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), P.L. 110-275. Specifically, this letter provides information about the sections of MIPPA that relate to the Medicaid program.  Many of these provisions are intended to remove barriers to applications for the Medicare Part D Low-Income Subsidy (LIS) and the Medicare Savings Programs (MSP). To access the letter, click here. (CMS, 2/19/10)

Helping People with Alzheimer's and Their Caregivers
The Reducing Disability in Alzheimer's Disease (RDAD) program provides exercise training for people with Alzheimer's disease who live at home, while at the same time training their family caregivers about how to manage behavioral symptoms. It reduces behavioral symptoms and depression and improves the participants' physical functioning. RDAD is funded through the U.S. Administration of Aging's Alzheimer's Disease Supportive Services Program. To access the article, click here. (ODA, 3/1/10)
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PALMETTO GBA NEWS

March 2010 Medicare Advisory (2010-03)
March 2010 Regional Home Health and Hospice Intermediary (RHHI) Medicare Advisory (2010-03) is now available. (PGBA, 2/24/10)

March 9, 2010, Hospice Teleconference - Hospice Direct Data Entry (DDE)
Palmetto GBA will host the Hospice Direct Data Entry (DDE) Teleconference on Tuesday, March 9, 2010, from 10 a.m. to 12 p.m. EST. For more information and registration, click here. (PGBA, 2/26/10)

Hospices Billing for Physician Services Change
CMS has made radical changes to the way physicians bill for Evaluation and Management services by changing the CPT codes they utilize.  Hospices are sure to get questions on what codes they should not use.  Below are three articles that will provide hospices some understanding of the changes so they can provide direction to the Medical Director and Consulting Physician Staff.

Reporting Hospice Services Provided by Physicians Under Part A
When hospices bill Part A for the services of physicians, they must use CPT codes that are paid under the Medicare Physician Fee Schedule (MPFS). Since the CPT Consultation codes are no longer recognized for payment under the MPFS, hospices shall follow the same guidelines for reporting E/M services as physicians billing Part B.  Hospices shall use the most appropriate E/M Codes to bill for E/M services furnished by physicians that could be described by CPT Consultation codes. To read the PGBA article, click here. (PGBA, 2/26/10)

Questions and Answers on Reporting Physician Consultation Services
This article is for physicians and non-physician practitioners (NPPs) who perform initial evaluation and management (E/M) services previously reported by Current Procedural Terminology (CPT) consultation codes for Medicare beneficiaries and submit claims to Medicare Carriers and/or Medicare Administrative Contractors (MACs) for those services. It is also intended for Method II critical access hospitals, which bill for the services of those physicians and NPPs who have reassigned their billing rights, and hospices where the hospice bills Part A for the services of physicians on staff or working under arrangement with the hospice. (PGBA, 2/26/10)

Reporting Inpatient Hospital Evaluation and Management (E/M) Services
This message is to clarify proper reporting in Calendar Year (CY) 2010 of initial E/M services provided by physicians (and other qualified nonphysicians when permitted) in the inpatient hospital setting that could be described by CPT Consultation codes that are no longer recognized for payment under the Medicare Physician Fee Schedule. The Centers for Medicare & Medicaid Services (CMS) previously instructed physicians and other providers to use other applicable CPT E/M codes to report the services that could be described by CPT Consultation codes. The CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians) who perform an initial E/M service may bill the initial hospital care CPT codes. Since that instruction, CMS has received inquiries specifically as relates to reporting initial hospital care services for which the minimum key component work and/or medical necessity requirements for CPT codes for initial and subsequent hospital services are not documented. For instance, one element of inpatient consultation requires 'a problem focused history' and 'an expanded problem focused history.' In contrast, initial hospital care requires 'a detailed or comprehensive history.' (PGBA, 2/26/10)
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Thanks to Don Pendley 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. (HNN, Volume 14, Number 9, March 2, 2010)


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