This piece was first published in Reuters Health. LMM President Randi Belisomo is a contributor.

The Centers for Medicare and Medicaid Services met Wednesday with 30 hospice and healthcare organizations after outcry over a new rule. The rule was designed to help avoid duplicate payments for hospice medications but may be having unintended consequences.

More than 40 organizations called for the rule’s suspension in a letter this week to CMS. Signed by the American Medical Association, the American Society of Clinical Oncology and the American Geriatrics Society, it argues the policy places “undue burden” on beneficiaries – requiring “dying patients to navigate payer disputes.”

Previously, hospices paid only for the drugs patients needed for symptom management, and Medicare Part D drug policies covered drugs for hospice patients’ unrelated conditions.

Under the new rule, CMS now requires a prior authorization process for hospices and Part D providers to determine responsibility of drug coverage, and hospices must cover medications not related to the hospice diagnosis.

The Office of the Inspector General recommended the policy to minimize mistakes in which Part D plans covered hospice drugs, but many hospice providers say they now face financial burdens that are not theirs to bear.

National Hospice and Palliative Care Organization President Don Schumacher calls it a “ridiculous regulation,” as the average daily Medicare hospice reimbursement is $160. “The margins are very low,” Schumacher said, and hospices don’t “have extra cash to spend on drugs we’re not supposed to be paying for.”

CMS did not reply to Reuters Health’s inquiries about opposition, sending instead a memo detailing the rule for Part D plans and hospices.

More than a month after the rule’s effective date, many hospices are also strained in administrative capacity. “When you’re talking about prior authorization, you’re talking about something that is going to delay services,” said Theresa Forester of the National Organization for Home Care and Hospice. The answer to how hospices and patients will manage these delays is unfolding.

At Journeycare, a hospice serving 500 patients daily across northern Illinois, the duration of admissions visits has lengthened. Case managers spend longer in homes, communicating with Part D plans proactively. “We are trying to eliminate families having to deal with denials and appeals,” said Penny Murphy, Vice President of Compliance and Quality.

Journeycare’s medical director, Dr. Martha Twaddle, calls the rule “unfortunate,” as providers experience greater challenges getting expedient care to the bedside.

“In the past, we might have allowed patients to continue a medication rather than engage in a negotiation,” Twaddle said. “Now, some hospices will be forced to be more forthright in stopping medications not shown to be helpful.”

Statins for high cholesterol and medications to slow osteoporosis and dementia are examples of those unnecessary for hospice patients, Twaddle said. Others – to treat certain lung diseases, for example, in advanced cancer patients – can enhance overall comfort, although they are unrelated to the terminal diagnosis.

“Some hospices may substitute less expensive medications that are not as effective, and you don’t want to be monkeying around when someone is dying,” Twaddle said.

However, Journeycare reports having enough capacity to manage the change. “There are many programs that do not, and I have a very strong concern for them,” Murphy said.

Angels Grace Hospice, located 40 miles from JourneyCare in Chicago’s southwest suburbs, may be among them. Serving 45 patients daily, the hospice reports a 30 percent uptick in drug costs. “We’re still navigating it,” said Chief Financial Officer Greg Zrazik. “We’ve taken the position that we cover all drugs while we assess the situation. It’s a fairly liberal, compassionate approach.”

Dr. Robert Arnold, of the University of Pittsburgh Center for Bioethics and Health Law, says the rule unfairly places the onus of larger healthcare problems on hospices that weren’t involved in putting patients on these medications in the first place.

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