MasteringMedicare.Net Episode 14 Hospice and Secrets of the Hospice Industry, an interview with Cathy Gurson
Guest:  [00:00:00] one of the things was we used to use years ago when I was part of another organization, we used to use liquid Adavan.
All the time that was part of the comfort pack. That's what came to help for patients with restlessness and shortness of breath. We would use liquid Adavan. yeah. For 
Alex: patients or their families. 
Guest: Well, all of us, we just put it in for everybody. [00:00:30]Hello everybody. Good morning. This is dr. Alex any welcome to mastering Medicare. We're so excited to bring a new guest, to our podcast today. And my cohost, dr. Amy Schiffman is going to introduce her. 
Amy: Okay. I am so excited about this podcast, Alex, mostly because I've wanted to have Kathy yeah. On this podcast since before COVID, [00:01:00] but then coach the canceled and then everything fell to, you know, poop.
And that was that. All right. So I am so excited to have with us today, Kathy Gerson. Now, Kathy, I know because she and I worked together. She was, I'm just going to call you like the chiefs are in charge of a hospice and I was the medical director of that hospice and we basically. Started a hospice together, although you really started the hospice, I just kind of like watched you be super organized and super amazing with it.
And we actually went through a [00:01:30] Medicare. What would you call that? Like, we actually started a hospice. They had like, come and decide that we were hospice worthy. We've got all the way through, from like a twinkle in someone's eye to a full fledged hospice. What is that called? 
Guest: That was, are of course I can't remember the name of it at the moment.
And that was our, our certification 
Amy: certification visit. Like we started a hospice slash you started a hospice. So Kathy is amazing. She actually has not just done. Hospice work has done home. Health has been the executive director, [00:02:00] Bob. Home health agency has worked in hospice for 10 to 15 years, which seems like a very broad range, but okay.
And it's either 10 or 15 years, we've lost five years somewhere. And, we have, have enjoyed the benefits of learning together and I'm trying to master a Medicare together if you will. And I'm so excited to have you on the show today because today is going to be all about hospice, which it's almost tragic and embarrassing that we haven't done.
Hospice [00:02:30] until now, given that so much of what I have done that has helped to define me in terms of what I've done for the past 10 years has been in the hospice world. But we're going to talk about that part, a benefit, Alex, that part, a benefit called hospice. Are you guys right? 
Guest: Yes, 
Amy: you're so ready. Okay.
So Kathy, why don't you tell me what your first. Job is to do for somebody who wants to be in hospice. Like, what is it that, what is the job [00:03:00] of a hospice when someone wants to be on hospice or in hospice or on hospice or whatever we say. 
Guest: So I think it's really important first to understand how that person comes to hospice.
If it's going to be a doctor calling us to say, I have a patient who I really think needs hospice, or if it's a family member who's calling to say, I've heard this word floated around my loved one, and I want to know what it means. And I want to know more about, how this is going to go, go on for them.
So it really [00:03:30] depends. You have to assess the education level of. That person around how much they know around here. And sometimes these primary care physicians, they also don't know a lot about hospice and they think that, okay. Hospice is a hospice is a place where, you know, it doesn't seem like anything else I can do for this patient.
So hospice, I guess. And so they're kind of coming to you with a question, Mark families come to you with a question Mark. So really the first thing we do when [00:04:00] we, when we answered to the phone for that new person, that new physician, that new loved one is to find out what they know about hospice. and we'll ask where there, you know, tell us what's going on.
Tell us about your loved one. Find out if they've recently been in the hospital, what were they there for? And start to feel it out, to get more information so that we can start kind of building, the plan for them. Ahead of time. 
Alex: So I, for the benefit of our [00:04:30] audience, I do want to step back for a second.
Cause we, we live in the weeds. I do want to start from the top level. So Kathy, could you kind of give us a high level recap of what is hospice 
Guest: I would love to, hospice has always been my. Absolute passion. So the, to have somebody ask me about, to give you the bare bones of hospice, I would, I would love to do because it's something I really love talking about and something I really love educating about because it's such an important, such a valuable [00:05:00] service to people.
So hospice is a service that's covered by your, the party benefit of your Medicare. and it's covered at a hundred percent. And what that covers is, End of life care. So when a patient has received a terminal diagnosis or no longer wants to seek curative treatment for their condition, and a doctor can see, can safely say, confidently say that they wouldn't expect them to live longer than six more months without any, ex [00:05:30] life extending treatments, then that person would be eligible for hospice.
So it's for people who, Are ready to no longer seek curative treatment, but still want to be cared for and have their symptoms managed. those are the folks that we're looking at for hospice 
Alex: and what I find really interesting. And I didn't know until Amy taught me and maybe you can talk a little bit about this is that once you enter the hospice category of [00:06:00] Medicare, like from the billing and reimbursement side, It seems like you're kind of carved out from the, or pulled out from the other elements.
Right. You're not then separately building for 
Guest: encounters 
Alex: for part B and other things. Right. Can you talk a little bit about that? 
Guest: Sure, sure. There's like a really good, You know, reason for that to be the case. So the, the hospice benefit itself from part a is extraordinarily generous, in terms of, in comparison [00:06:30] to a lot of the other elements of what Medicare covers.
So when you're in hospice, Everything is covered at a hundred percent. Yeah. The medications that the nurses bring in all of the nursing visits, all of it, the chaplain, the nurses, aides that come in to do the personal care, any equipment that a patient would need. So an electric bed like you have in the hospital or oxygen or bedside tables, I mean, anything like that is all covered.
And because that benefit is so generous, then all the [00:07:00] other benefits, so a physical therapy benefit or the part B's or any of those, the hospitalization coverage is not covered concurrently when you're on hospice. Now that's not to say that you couldn't access those benefits if you needed to, but you would have to turn off the hospice benefit in order to be able to do that.
So in order to, If you wanted to explore physical therapy or you wanted to be hospitalized for [00:07:30] some reason, you want it to have that, that surgery or whatever it was. First of all, those are conversations that you'd want to have before you started hospice. So we've had we talk about whether or not you were ready to say, listen, I don't want to try physical therapy again, or, or, you know, I'm, I don't want to do that exploratory surgery or that, that experimental treatment at the hospital.
I want to do that anymore, but yeah. And then you would come into hospice, but those benefits can not run concurrently. 
Amy: I want to Alex, Alex, I want to out [00:08:00] Alex, Alex, I want to take it up one more step. Which is to sort of review even at a higher level, the party benefits so that we do totally understand that there, yes, once you have chosen one of the part, a benefits to be in, like while you're in the hospital, you cannot be in hospice while you're receiving Medicare part, a home health at skilled home health benefit, you cannot be getting hospice while you were in a nursing home receiving rehabilitative treatment.
[00:08:30] In that nursing home, you not, you cannot concurrently be in hospice. So the four elements of part, a Medicare. You can only be getting one of them at any given time time, because you are basically what is called reassigning, your benefits to hospice. However, I am going to say one thing and Kathy already knows this, but I'm just going to clarify it, which is the part B services.
As an example, let's just pretend you are on hospice, but for some reason you still need to [00:09:00] go see your endocrinologist. For whatever reason, and it is not part of your terminal illness, the reason that you're going to see that endocrinologist those benefits will be covered. There are some weird billing issues that that endocrinologist needs to understand.
And actually there's tremendous misunderstanding on the part of both specialists and primary care doctors about, Ooh, that person's on hospice. Nope. Not going to take care of them. Never going to get paid. Never going to just don't come in. So they're there misunderstandings there's actually, [00:09:30] Like a GV and a GW modifier, which, somebody can use when they're sending in their 1500 form or billing through whatever billing mechanism they have to bill Medicare that will allow a doctor to actually bill for services under part B.
Even if the person is on hospice, but an oncologist might have trouble. If the person's terminal diagnosis is let's say breast cancer and they send in a bill that says, Oh, I'm seeing this person for breast cancer. It's questionable as to whether or not that. Oncologist will get paid [00:10:00] for that visit. 
Alex: Very interesting.
So I did not know that if it's unrelated to the hospice, patients encounter could still be billed separately, but, putting that sort of exception aside, it almost seems like hospitals should have been made like a part age for hospice. Cause it's kind of like. It's kind of like an ma plan where they're rolling everything into one and you're getting a, a, a per diem, right.
Which is essentially the same [00:10:30] concept as an ma plan, whether you're getting a set amount of money. and then the ma plan or the hospice essentially. Meaning that the hospice has to then kind of take care of it, 
Amy: right. That risk that is hospice is at risk. They have to manage their dollars. Right. Kathy, 
Guest: tell me twice 
Alex: the hospices kind of like an ma plan for those who are end of life.
Right. Am I summarizing it? Right. and so to be clear, when you, When you say [00:11:00] that, all those benefits that you talked about are quote, unquote covered. what we're really saying is, is that CMS is paying the hospice agency a certain amount of money for each hospice patient. And then, and then when that hospice, patient needs certain things, the hospice agency is the one who's covering those costs.
That's correct. Right. That's correct. So talk, talk about, you know, when we, when we talk about that. Yeah. The concept in, in the [00:11:30] analogous kind of M a plan, it's in the best interest of the ma plan to, you know, to, to limit resource utilization. So how do you, how do you, when you're trying to make money, right.
Which is a little bit business interests of the hospice, right? You don't want to use too many resources yet you have, you know, your, your patients are the most fragile and, potentially, you know, in need folks out there, Like, is there some [00:12:00] conflict there? Is there some discomfort that we'd like to do this for this person, but we just can't afford it or is there some really happy medium that, that hospice has been able to find where they feel really comfortable, that they're able to do what the patient needs and, and still, you know, run a legitimate business.
Guest: I think there are a lot of ways that hospices can really manage that, that fine line. And a lot of it comes through education, and [00:12:30] that educating your staff and that's educating your patients and their families because when the families and the loved ones and the patients feel, comfortable in what's happening and what the course of treatment is and what to do when and who to call, when you run into less crisis care visits, you run into less.
Situations where decisions need to be made quickly. And sometimes the easiest thing to reach for, to solve this problem is, is the most expensive thing. but you educate your staff too, and you talk about, [00:13:00] different ways that you can, can serve the same purpose, but perhaps at a, at a lower cost point, one of the things was we used to use years ago when I was part of another organization, we used to use liquid Adavan.
All the time that was part of the comfort pack. That's what came to help for patients with restlessness and shortness of breath. We would use liquid Adavan. yeah. For 
Alex: patients or their families. 
Guest: Well, all of us, we just put it in for everybody. so we would have liquid Adavan it [00:13:30] turns out liquid Adavan is tremendously expensive.
And the other thing about liquid Adavan is it comes in a big bottle with a lot of doses in it. So. You'd end up wasting quite a bit of it if a patient passed and it was a very expensive thing. and so we came to find out that we could actually get tablets. Of Adavan we can crush them, put them in just a few drops of water, still bring them up into a syringe to give them to someone who couldn't take an oral tablet comfortably and still be able to get it into that mucus membrane.
And it was significantly cheaper. [00:14:00] So finding places like that, where you can make a substitution where there the outcome is the same, but the cost point was, was much different. Understanding and that's educating your staff, about what time we're going to be ordering what equipment you can use that, you know, you don't have to get the Ferrari every single time unless it's needed.
Let's, let's figure out what the patient needs and get them, those things. And then. And then build out as we need to. 
Alex: does, I want to [00:14:30] understand kind of the mechanics of the business of hospitals a little bit, cause I think that gives me a good framework for then understanding the clinical care. Does, does every hospice patient generate the same per diem for the agency or is it more like an ma plan where it kind of depends on how sick or complicated they are?
Guest: so. Every patient generates the same per diem. that depends on where they are in their hospice course. So after the [00:15:00] first, right, so every patient who comes in on every patient, on day one, it makes the same per diem as every other patient on their day one. And once you get to, 180 days, Then the hospice is reimbursed at a different rate.
So all the patients who are on that day number are reimbursed at different rates. So there's no,  difference. There's no reimbursement based on acuity. The only thing that I would say may come under that. And is that in the last couple of years, [00:15:30] there was a change to the plan where patients in their last seven days of life, there was this bump up.
So in the last seven days of life, patients usually see more visits from, their nurses, from their social workers, from their chaplains. The age as that patient is transitioning now, as they're moving. towards the end of life. And so when you start to see, see that spurt of visits, start to pile up, and yeah, increase for that patient.
Sometimes multiple nurse visits a day to manage those [00:16:00] symptoms. There was an allotment that was added on to those per diem days in those last seven days, if that patient was experiencing increased visits. 
Alex: So is that like a retroactive thing that, if there's a lot of visits and then the patient passes, then retroactively say, Hey, we need to be scared.
Guest: I see. Yeah, that was, that was part of the discharge form. Then you indicate how many visits they received from the different disciplines. in those last [00:16:30] seven days, 
Alex: can you give us a rough idea of what is the per diem for a hospice patient? It 
Guest: really depends on where you are because it's based on locality.
so in Northern Virginia, any what? Well, 
Amy: we just have one 85 range. So, the funny thing is, is that, so part B in part, a Medicare are not managed the same way under Medicare. They have different like max or people who oversee the administrative side. so what. Is for part B in terms of [00:17:00] sort of collecting and billing and assignment of, of dollars is very different than if you were looking at part a and like, so Northern Virginia is not in the same bucket as let's say, Montgomery County or the district of Columbia or Frederick County.
In fact, Montgomery County is actually in the same bucket as Frederick County. And thus, because of some weird thing within Medicare gets co collects a lower amount. Per day, like somewheres between one 55 and one 75. And I'm sure somebody [00:17:30] will be like, no, it's one, you know, 76, but you know, it's lower than Northern Virginia, Northern Virginia is collecting a higher premium.
So basically just, just to, just to continue to sort of elaborate on this. Yeah. It actually really forces me to have to ask Kathy about a couple of things. Number one is not all. Hospice is not all hospice care is the same. We actually sort of. Touched upon that in terms of what end of life could look like in terms of resource utilization, but there are numerous different sort of [00:18:00] resource level of hospice.
In fact, we all talk about hospice and we think of hospice as hospice providers, as in home hospice sort of most people, yeah. Somewhere between 60 and 90% will receive. Almost a hundred percent of their hospice care in their home. People, hospice is not a place. I mean, honestly, Alex, this is just a little reflection when I was an ER doctor, I just thought that hospice was like a place like it's like, it was like hospital spelled.
It was like a misspelled. I was like, Oh, you [00:18:30] meant to put a hospice title. Like what is a hospice? It's a place. Right. Did not realize that hospice is like, State of being it's like, Ooh, I'm in the hospice, but it's, it's just a, it's just a billing mechanism within Medicare. You're just a new, it's a new way to bill.
Alex: Not only are most doctors, convinced that hospice is a place because that's all they've ever been told, but I knew it had to be in silver spring. 
Guest: Like, it just 
[00:19:00] Amy: feels like that's where
please don't Sue us.
Alex: Yes. Is 
Amy: eventually, 
Alex: okay. So just one clarification. Since most people think that it is a place, if it's not, I know, but if a patient actually needs, I kept 
Amy: go above you. I have to go above your pay grade right now. I can't [00:19:30] because, so if most people are receiving hospice care at home, there are levels of care that will get you to that place, Alex, like you could go and stay in the hospice place.
If you have certain specific needs, Kathy, take it. Why would you need in general? 
Guest: So there are actually three levels of hospice care. The first is regular hospice. That's regular, wherever a person calls home that can be home, that can be [00:20:00] their home. sometimes people go and stay with, with children or with, siblings, to have a limited life.
Assisted living assisted living all of that, right? Wherever a person is comfortable, wherever they call home, that can be the hospice, and all those staff and all that, the disciplines will come to that place to give that person care. and that assumes that the person is, their symptoms are managed, that they are comfortable, that all of the needs that they have can be adequately met in that space with those [00:20:30] caregivers around them.
So if that person, however, starts to have, or, or not, or always has symptoms that are. Are difficult to manage in the home. Perhaps they require an hourly or every 30 minute medication for, some of the symptoms we see or maybe seizures or, just constant vomiting or pain that just can't be controlled symptoms that are really, you know, off the charts.
Then we can place that person in what we call general [00:21:00] inpatient. And that has to go with a facility that the hospice agency has contracted with them in the past. And they, they work with that facility to get a bed and that patient can go stay in that bed, in that facility. Now, now general inpatient, which is a brief created GIP, is meant to be.
24 48, 72 hours. And generally, so that the symptoms can be brought under control by professional staff. So the nurses [00:21:30] in that facility who are there, who are able to give the medications who are able to call the hospice physician or the hospice nurses to titrate and change those orders as needed based on the symptoms, to get that patient under control.
And then ideally that patient is able to then go back to. the place where they had been. Similarly, we have another level of care that's called continuous care and continuous care. It's kind of like GIP general inpatient in the home. and we will [00:22:00] put staff in the home around the clock. In order to be able to get those symptoms under control.
again, it's not meant to be more than 24, 48, 72 hours at most in order to get those things under control. Now, I think when we talk about continuous care and when in the past, when I have said the words, we'll put staff in your home, around the clock, A lot of times families, or groups that I'm talking to their ears will shut off and that's all they heard.
And then, yeah. Yeah. Like 
[00:22:30] Amy: exactly like, like the hospice angels have flown, right? Like, Oh my God, this is exactly what I wanted, but.dot dot. 
Guest: So there's, there's some sort of societal expectation that when somebody enters hospice that suddenly the whole hospice team moves into their home, there. For them around the clock, that suddenly you are, you know, given a, person who will be there forever to care for you around [00:23:00] the clock.
And so one of the most shocking things that people learn about hospice is that, that isn't happening, that this isn't putting a caregiver in your home and that our goal. Is to make sure you have a caregiver, a neighbor, a friend, a child, a sibling, a spouse, someone who is able, willing, and able to be taught, what the symptoms are, how when to call for help, what to give for this, what to give for that, and teach them about how to care for their loved one in the home.
I think that is [00:23:30] usually the most startling thing that people learn about hospice. 
Amy: Yeah, it's a quality indicator. How well, you know, the, after someone dies and they receive, let's say a survey from CMS or from the hospice themselves, that is one of the quality criteria is how well did your team teach you?
Because you, everybody who is in the family becomes essentially, or, or the staff in an assisted living becomes a teachable caregiver. That's a key word, a teachable caregiver. 
[00:24:00] Guest: And as an editor, as an administrator, we would be able to measure how well our patients were being, and caregivers were being taught by the number of calls that we would get.
After hours. and so to be able to look at those calls and say, why are people calling to get medications reordered at six o'clock at night? Why are people calling to ask which medication do I give for this or that? And that's not to say that that, you know, people can't. Gloss [00:24:30] over when the nurses there, because there's a lot of information coming and they don't remember it, but you can start to trend and track and see, you know, maybe that, that particular nurse and maybe that particular team member is not giving all the great information while they're there, because people are still calling for supplemental information on the regular.
So it's, it's a good way to measure how your team is educating as well. 
Alex: When a hospice patient is. I in inpatient status or, in the GIP or the other [00:25:00] level that one of the two higher levels above the regular home hospice. does the per diem increase or it's the same? Yeah. 
Guest: Yeah. Significantly, 
Amy: because that was the exception, right.
That we were trying to talk about, which is the per diem goes up, but actually most hospices and Cathy that they lose money on the per diem. Once you start going to the higher levels of care, because doesn't really go one to one with the actual resources, many hospices use cath, right? Like a, an LPN to provide the, The around the clock [00:25:30] in home care.
And then once you go to GIP hospice, if you've contracted with, somebody, it often is just a complete and total wash, meaning like you might make 800 bucks a day, 24 hour period for having GIP care. But almost all of that goes to paying for the contracted rate that you've gone to for that patient. So in essence, you make no money on the days of the patients in GIP care.
Guest: So it's 
Alex: all about keeping them in, in, in the huh? A 
Amy: hundred percent. Yes. Keeping them in their home. That's right. That is correct. 
[00:26:00] Guest: Because while that person is still in GIP, you still are sending your staff in to see them, but your nurse still has to go in to see them. So you're still, you know, having that nurse visit happen, even though there's a facility full of nurses there, your staff is required to still be there.
and the other, the other interesting feature too, is that, it goes on eight hour segments. So if that patient is in the facility for, eight hours or more than you have [00:26:30] to pay the daily rate that's so w so if the person is in, a GIP bed from. Midnight to 7:00 AM. Then you don't get the GIP rate from Medicare for that rate for that day.
Even though they were there, even though you still have to pay the facility. so if the person passed away before eight hours in the day, you'd still have to, you wouldn't count as a GIP day. 
Amy: Yeah. Th the hospice is completely at risk. Like they have no control if the patient is going to die within those first eight [00:27:00] hours.
But if the patient dies before that eight hours, you actually do not receive the GIP care, even though GIP care rate, even though you've been providing GIP level care, 
Alex: Talk to me guys, before we go more into the weeds, kind of about the industry. Are there like national players in hospice or is it more mostly mom and pop shops and kind of talk to me about that.
Guest: It really depends on where in the country you are. there are big players, [00:27:30] there are big, organizations, United healthcare all have, you know, a lot of times the big hospitals in the area we'll have visiting nurse associations that have hospices associated with them. What's really interesting. I think in the industry is where you can't get hospice or where you have challenges getting hospice.
And those are in the more rural areas. because those nurses. And those organizations have much more mileage and it's square footage to be able to cover, where we live in a very population, dense area. There's lots of patients. There's [00:28:00] lots of, people who have the skillset to be able to work in a hostel, listen, to make those visits and then getting around to see them during the day or, or even in the evening is.
You know, a manageable task, but when you go out a hundred miles from Northern Virginia and you're out in the mountains, there's one hospice agent. You see that services a lot of that area and it is a lot of area. So I'm a late night call could be, you know, several, you know, 30, 40, 50 miles I'm in the dark, down a road.
That's not paved to a, you know, [00:28:30] so you're dealing with an entirely different. demographic. And so hospice in populous areas, it's not a, it's not too much of a challenge. I mean, there are challenges, but not compared to the challenges of, of people who live in more rural areas, being able to access hospice care.
And I think that's where people start to talk more about hospice as a place. Because we would see maybe, places setting up what they call a hospice house, where they would maybe be able to bring patients in from more rural places to be in [00:29:00] a, kind of a, a miniature facility of sorts where people are getting hospice care in a, in a single place.
Amy: So I'm going to add onto that. So just back to what Alex asked a little bit in terms of, the industry itself. So there's a huge difference between what's going on in Virginia than what's going on in Maryland. Virginia is not a certificate of need. State. Maryland is a certificate of need state. What does that mean?
It means that in [00:29:30] Maryland, you actually have to apply. To becoming hospice in a County by County way where the state has already decided how many hospices. Have actually can actually serve a specific County and it's based on population. So it's kind of like the medallion of taxi cabs in New York city.
There's only a certain number of these that can be issued for any given County. And they're like gold people wait around to be like, Ooh, I [00:30:00] wonder if they're going to go South. And then they like grab up their certificate of need and there they're sold for millions and millions of dollars. Really. 
Guest: Yeah.
Some 
Amy: people are sitting around waiting for these certificates to open up. because hospice in and of itself is a, can be a fairly profitable business. Yeah. If you look at it in terms of what is the bare minimum I can provide, what is the bare minimum amount of services that I can put in there? What is it the actual regulation say, Oh, if I just do exactly what the [00:30:30] Greg say and kind of do it without heart, you actually can kind of go print money in the back of the office.
because it doesn't say that RNs have to do, do all the visits. It actually says LPN can do a lot of the visits, but a lot of hospices are like, we're never going to do it with LPN. We're going to do it with RNs because that's the spirit in which we wish to do this. There's also a huge, issue within the industry as you know, for profit, not for profit.
And, and one of the things that's interesting is that the not-for-profits often do a lot of fundraising. So then they can provide extra services. [00:31:00] There's some hospices in the area that actually will say, Oh, you, you need blood transfusions. They'll have enough money to say, Oh, we can do blood transfusions in the home.
Even though hospice benefit doesn't pay for that, they will provide services that make. Almost no sense to a for-profit hospice to do like transporting people to continue dialysis, all sorts of stuff can happen while you're on hospice, depending upon which hospice you choose, because the industry is a comprised of for profit and not for profit and [00:31:30] B some of these giant.
Like national companies, will provide different other types of benefits. I have now worked for several hospices. Some of them do not provide any continuous care whatsoever. Like I didn't even know what continuous care until I had worked at, at, at one specific hospice. I didn't, that was just not a level of care that was ever utilized in one of the hospices that I had worked for.
And then there was another hospice that used it. Use GIP care all the time because they were affiliated with a hospital. So, because they were affiliated with a [00:32:00] hospital is really easy to transfer patients from inpatient hospital to GIP hospice. So, you know, and then there's places that actually have built this beautiful hospice house and you know, it like it's super cache and it sounds really, you know, great for families.
Oh great. There's this beautiful inpatient hospice, not realizing that like less than 1% of all the patients will ever. End up receiving care there. And so, just so to give you a perspective in Montgomery County, there are several for profit [00:32:30] hospices that are large national companies that are associated with either Manor care or, that are themselves sort of standalone giant, publicly traded hospice agencies.
and then there's a lot of nonprofits, so it actually varies. And then in the state of Virginia, where there is no certificate of need, you could literally say, Oh, I think I'm going to start a hospice. Hmm, we've done that. And then just pretty much start a hospice, assuming that, you know, there's not going to be any stark laws about it, internal, internal referrals and saying, Oh great.
We have this whole spectrum of care. We've got, maybe [00:33:00] we've got a home health agency that could feed into a hospice, or we've got a private, a private duty agency that could feed into the hospice. So there's a lot of ways of looking at this. I think I've spoken enough. That's all I had to say about that.
Alex: So if somebody starts a hospice and you're getting this per diem, is it basically, is it mostly up to you internally? How you function? Like if you want to do most of the care virtually, is that up to you? 
Amy: Virtual? Oh, COVID style, but not in reality. No, you can't do virtual care and hospice, except for COVID style.
Alex: I could [00:33:30] like your shouldn't or you're not allowed to, or. 
Guest: You supposed to, you have to make, I think a nurse has to make a visit once every 10 days. So we usually make a weekly visit or based on the patient's need, because you know, what you do in the moment is, is one thing. But when you, when Medicare comes in to do their, credentialing visits, when they come back to do their, their, their checks, they're looking back at your charts and they're saying, well, you've been charting that this patient had all these symptoms, but I don't see that you ever sent a nurse out.
Okay. So then that [00:34:00] starts to look at the quality of service that you've been providing to these patients. They also have,  statistics. They want you to be able to meet certain help. What percentage of your patients ended up in GIP? How many of your patients ended up receiving continuous care? So you can make the argument that we manage our patients symptoms very well and very proactively so that we didn't have to use those services, but your documentation better show that.
in the end, because they're going to say, well, why did 75% of your patients go to [00:34:30] GIP? Or why did you know these kinds of crazy numbers? So you want to be able to manage, you know, why your patients are in the level of care that they're in, and be able to justify that with them documentation, to show that you're, you're doing the work that you should be doing when you're taking those Medicare dollars.
Alex: So if I'm a family member or a geriatric care manager or a physician, and I need to refer, you know, somebody to hospice, how do I choose? What questions should I be asking? How do I know who's high quality, [00:35:00] who's low quality. 
Guest: I think there are a lot of ways to do that. you know, as a consumer, you can always go to Google and look at the reviews, see what people have put.
I hate to say that having, having worked in hospice, I would, you know, people would 
Amy: got very sick to my stomach. When you said I like suddenly just was like, Hmm, 
Guest: I was trying to be very reliable cause in the emergency. 
Alex: In the emergency medicine world, like in my career, I, I calculated, [00:35:30] I estimated that I must've taken care of at least, I don't know, 30,000 patients or something like that.
And I have like four reviews on Google and like four people were upset with something that happened in the ER, you know, there wasn't even under bike control. So like I hate that. Is there some better 
Guest: way? Well, there are a couple of other ways to thank God. You know, you can ask around if you are a family member.
usually geriatric care managers. They know, they know a lot of that. A lot of them have come out of the post acute [00:36:00] space in some way, and they know the players and they know the places that they like. A lot of times they have friends, certain places and they can feel comfortable about recommending their patients to those places.
there are, because Medicare does come out, they do give stars, like a restaurant like Michelin stars. to these agencies and you can look that up online and see how each agency was ranked under the, the qualifications that they were ranked under and the different scoring that they got. And that have you an idea, or this agency is two and a half [00:36:30] stars in this one is four stars.
and that can give you a clue as well about, about those agencies. But when you're a patient or a loved one, you can talk to the community that you're in your church community. your, you know, your work community and ask, ask, you know, has anybody used a hospice agency? What did you think? Some people will say, Oh gosh, I used this one and it was awful why?
Or this place was so great. You know, you thought. All Facebook, you can go onto, I know there are tons of message boards where people kind of send out these little, you [00:37:00] know, feelers to find out about that. Another really great way is to just. I mean, nobody opens a phone book anymore, but open a phone book and call them and ask questions.
ask about how many patients they have on their census ask about whether or not they've been credentialed. if they've received certifications above and beyond the Medicare certification, 
Alex: you can ask of those certifications that folks should ask 
Guest: about. So they're the one that certifies, for home health communities [00:37:30] and hospice is called chap.
acronyms are my kryptonite, so I can never remember what stands for, but it's an agency that comes out and there it's above and beyond Medicare. So, so meeting Medicare regulations is one thing, but if you'd like to be certified by chap, you need to really go above and beyond and they have metrics. Of excellence that you meet in order to receive that certification.
And that's right. 
Alex: Chap as in C H a P. 
Guest: Yes, it is chap certification. 
Alex: So [00:38:00] that's so other, other than asking about the size. So do you think a large paid to patient census is a good sign or a bad sign? 
Guest: it depends. It depends on, on the ratio of the nurses. How many patients are, are. Assigned to each nurse you can ask about what their on call situation is.
Does the nurse answer the phone or does it go to a call center? how long does it take for somebody to come to you in a crisis in the middle of the night? if something's [00:38:30] happening, is that call going to take two hours or is that nurse going to be there in 30, 40 minutes? those, those are questions.
I think that are important to ask. 
Alex: What about those are, those are great. Katie, what about, are, are any hospice agencies, doing new stuff, like using software to create like chat groups? So it, family members can all chat together with maybe a representative of the hospice so that they have an easier, like group conversations are like, is stuff like that going on.
Guest: That I have not heard [00:39:00] of going on 
Amy: vaping, digging out. Alex is like, I've just, Amy, after this call can wait. Let's talk about our new business idea. 
Alex: Well, it seems like, yeah, go ahead. Go ahead. Go ahead. Sorry. 
Guest: No, no, it's not something that we'd had before. it's really just old school phone to call and you speak to the nurse on call, explain to them what's going on.
I think the most high [00:39:30] tech. That we ever got was to do a FaceTime in a real emergency. We could get onto FaceTime and help that person before we were able to get to the home to start, you know, saying, okay, well you see here, and this is, you know, the dial on the oxygen machine that we can adjust and using that.
And, and, and as dinky as that might sound, that's really all you need. a lot of times when families call after hours, or anytime they're calling you, they're seeking information, but they're really seeking comfort and they're [00:40:00] seeking reassurance. And so sometimes just having an expert on the phone or the nurse on the phone in order to, let them know that what they're seeing or what they're hearing is normal.
giving them instructions on what to do just makes them feel better in the moment. 
Alex: I presume that folks who work in home become really good at identifying when it's likely the patient's last day. when you identify something like that, what do you do? [00:40:30] Do you send a nurse to the patient's house? Do you notify the family?
Like what kind of happens in that? For those final moments. 
Amy: And Kathy, before you answer, just use the word that he's trying to, he's trying to use a word. He just doesn't know what that word is transitioning. 
Guest: So transitioning is that is the term that we're using. When, when we really see that person start to move into a phase of actively dying, and transitioning can really happen very, very quickly, or it can kind of happen over, [00:41:00] you know, a period of time.
Everybody's different. Everyone does this a little bit differently. but me as a hospice nurse, I want to be very communicative with the family and I want to let them know what I'm seeing. And I never would say something like, give, give a precise time estimate because people really try to hold you to that.
And that's a really, that's dangerous to her. Sorry to get into. So usually I would say that this, you know, it seems as if your loved one has. Hours to days or days [00:41:30] to weeks, those kinds of estimates are, I think are safer to work with. but it starts letting people get their mind around what's happening.
and then basically it's symptom management. If that person is comfortable and they're transitioning, probably family understands what's happening family. Is it ease patient? Is it ease? There's no need to, You know, send in the cavalry to that patient's house, unless there's something that needs to be managed in that.
you know, you may ask the nurse to go out more frequently, every day, [00:42:00] maybe just to check on the patient, check on the family. but there's no need to, you know, get crazy at the end. 
Alex: Got it. I don't know. Let's say Amy's having a seizure there. It seems. 
Amy: All right. I aspirated my coffee. I'm all good. 
Guest: Do you need a nurse?
Amy: Alright, wait, this could go really South quick. So I'm just gonna ask a quick question, [00:42:30] Kathy, in your experience, what are the types of symptoms that when somebody is transitioning, do 
Guest: they have, again, it's so hard to say in general, but well, in general, yes. people's breathing changes their vital signs start to change.
By that, I mean, they'll either be trending one way or the other. So either breathing starts to really slow. sometimes you can hear, everyone loves to call it the death rattle because that's the, you know, the word that everybody knows, but you hear that kind of congestion in the, in [00:43:00] the throat when they're breathing, or breathing become, can become very rapid, as well.
Or we're really seeing vital signs on one side of the spectrum or the other heart rate and blood pressure are going in one direction and it's trending in that direction up or down. And the patient may also start to be a little bit more withdrawn. they may not be needing or asking for food or drink.
and that I think is one of the most distressing things for families, because they may be comfortable. They're breathing. All [00:43:30] right. they don't seem to be in any pain, but when they stop. Being able to eat and drink or stop asking for it, or when they put the straw in the mouth and the patient doesn't sip.
That is a lot of times what really upsets the family, because I think that's when, when the reality of the situation starts to set in for people. and we start to have conversations about when those nutritional needs, start to decline because that patient doesn't doesn't need that nutrition anymore.
their body doesn't need that fuel anymore because the body is slowly starting to [00:44:00] shut down. 
Alex: Does hospice pay for or help arrange for nutrition? 
Guest: Well, that's a tricky question. So the big answer is no. but there are lots of little yeses around the sides. we, when it, when a patient is no longer able to eat or drink on their own that's, that is, that could be part of the terminal diagnosis that could be part of.
The disease process for them. If [00:44:30] we start to introduce, intravenous fluid, or, or intravenous feeding, or a patient has, a G tube in their stomach where they receive tube feedings in their stomach, it's, it's really, it's kind of a conversation about whether or not that is a natural death, or if that is.
Artificially prolonging life. so it's, that's, that becomes a different kind of conversation. Some people can talk about whether or not. [00:45:00] A person feeling a tube feeding is his comfort. Are you providing them comfort with that? It's, it's a, it's a whole other attitude 
Amy: tattooed in all of this. And actually, it is often a big question Mark.
When somebody comes onto hospice and they have a G tube and you know, that the only reason that they're still with us is because the G tube feedings continue because they, they can't they're. Let's just say they are essentially the non-communicative nonverbal. [00:45:30] And the only thing that's keeping them going is the, is the G tube feedings.
There are people like that, that who stay on hospice for prolonged periods of time, but it becomes part of the dialogue of what your loved one would have wanted. This was this part of how they would have wanted to live. I mean, essentially you are giving them, you know, 1200 calories, 1500 calories a day through a tube in their stomach, but they don't communicate with you.
All they do has to have inputs and outputs. And, and that is, that is actually a really different thing for a lot of, staff members, philosophically, You know, if, if the idea is when you [00:46:00] come on to her hospice, there's a, there's sort of a, a broad view of like, what is, is, you know, what is supportive care and what is not supportive care?
And it becomes a conversation. And, and, and so there is a broad spectrum, Alex, of like, what is appropriate and what is not. And, and then of course back to the idea of like, what does a hospice willing to pay for? You know, I think, I think that that's, that's also part of that conversation. It's not like set hard and rule hard and fast, like Alex and I have talked a lot about like, why doesn't Medicare, just tell us exactly what they want us to do.
Tell us exactly what the rules are. [00:46:30] Why do they make us guess and make all sorts of judgment calls. And then later find out that we made the wrong decision and blah, blah, blah. This is another one of those too, where if they just said we will, or we will not pay for it, it actually would help to some degree, but it doesn't give clinicians the latitude sometimes a TA to help make some of those decisions.
Alex: I hate to take it in a cynical angle or a purely business angle. No, actually I okay. You're right. but I just, I [00:47:00] always want, I don't understand the flow of the dollar because that usually explains people's behavior. I'd say. so from the perspective of a hospice, would it not make more sense to.
Continue to provide the G tube feedings because it's keeping another patient alive that generates a per diem for you. 
Amy: Or what your hospice census is. If you want to continue the cynicism. I mean, if you're really trying to keep your hospice centers up and you're like, should change the change to Chang.
Is that what you're trying to say? 
Alex: Yeah. Or, or, but 
Amy: I guess [00:47:30] no, one's in there going, so listen on what we're going to tell you is, do not stop the tube feedings is that 
Alex: I, listen, I've never worked in a hospital. I don't know what's going on in the, in the operations side. Like, are people even thinking like that?
Or is it so. Sure is that like, nobody even thinks about the dollar or what 
Guest: you, you sure you certainly could do that. And, and from a purely a mechanical. Idea having those kinds of [00:48:00] patients would not be a bad thing. Why? Because, you know, there's  for all intents and purposes, they're stable. All you're doing is providing this, this feeding to them and someone will go in and bathe, everything becomes very routine then right?
The nurse comes in, the nurse checks them. Nothing's changed. The aid comes in, gives them a bath. They're not gonna be using your social worker very much. They're not going to be using your chaplain very much where I think you're going to run into the problem is around recertification. So at the end of whatever certification [00:48:30] period you brought that patient onto, and I know you've talked in previous episodes about the certification periods.
You need to be able to show at the end of six months that this patient is still hospice appropriate and it can't be a plateaued hospice experience. This patient has to have shown some decline somewhere. If they came in, as, as Amy said, not speaking, not communicative. Not moving then there's no where to show that they've had lost cognitively.
[00:49:00] Right. And if they haven't lost any weight, because you're continuing to put the same 12 or 1500 calories in them, you know, every day, then they haven't lost weight. 
Amy: There's no nutritional decline. 
Guest: You're going to have a hard time. If you have 32 feeding patients showing that they are still hospice appropriate through that decline, because if that patient is on.
A tube feeding. and that's the only thing really keeping them alive. Then over time, there will be places where you're going to see that [00:49:30] body start to decline. Yes. But it may not occur in, in the timeframe that you are looking to recertify them in. So 
Amy: that's an excellent point. That's actually so well stated, 
Alex: so, okay.
That's fascinating for me. I don't fully understand. So in order to mean, so in order to recertify the patient for hospice status, There must be a decline of something, 
Guest: correct? That's correct. 
Amy: Yeah. So Kathy, I was just going to say, to remind us that the certifications come in 90, [00:50:00] 90, 60, 60, 60, 60, 60. That's like the 90 days, 90 days, 66.
And at the end of the second certification period, you start requiring face to face visits. But even after the end of the first one, you have to be able to demonstrate nutritional, cognitive or functional decline. Where else you're out of hospice. 
Alex: So that's so weird because if you're providing really great care, maybe you're providing enough care to keep that patient, correct?
Guest: Yes. Yeah. Yeah. That's 
Alex: like, it feels like the arrows are pointing opposite of [00:50:30] each other in terms of what you're incentivized for is what's best for the patient. That's horrible. So, so, 
Guest: so you're really 
Alex: so like purely again, business cynical view, like, you're you, what you should be aiming to do is like maybe 90% of what's required to keep the patient stable because you, you, you almost want them from a business perspective to decline so that they can stay your patient.
Guest: You're like not, 
Amy: it's not like an IDT, like, Whoa, stop with the, [00:51:00] all the good care here. That's a terrible idea. But you know, people are super mission driven. So 
Alex: I know every hospice person I've ever met is like an angel on this earth, or they're amazing, but I'm just trying to understand the business and the mechanics of this.
Guest: It's so weird. It's a really, it's a really weird. Lying to walk because while you want to provide this patient with such great care and make sure that they're comfortable when you do that, so well, you lose a lot of [00:51:30] the, assessment data that you can use to. To move them into another certification period.
Now that's not to say that's all the time. Some of these patients will, will. Most of these patients will continue to decline despite that care. But, but it's, that cares. What's keeping them comfortable through that decline. So when patients let's take this to beating patients out of it, and that's why there's the tube, feeding patients are such a great area because.
You know what those tube feeding patients are going to be having [00:52:00] conversations with families, because there's a reason they put that tube that, that G-tube in to begin with. So you're going to have to be having conversations around, you know, what are we going to allow for natural death? And what does that look like?
and then inevitably you get into the conversation of. Do you just want my patient to starve to death? Is that what you're trying to do? You, you inevitably have that conversation. Well, they're just going to starve to death. and so you start having those conversations, but if we take the tube feeding patients out of it, and we talk about just [00:52:30] your, your classic run of the mill hospice patient.
Those patients are going to continue to lose weight. They're going to continue to show cognitive decline. you know, they're losing words or they're becoming, they're sleeping much more during the day. And those are things that you're going to be documenting to show that decline so that when the face to face with the physician comes up again, you can say, look, you know, at the last certification period, you know, mrs.
Smith was, was awake and talking and getting out of bed and toileting herself. But when I went [00:53:00] over the last couple of weeks, and now that I've gone to see her, you know, she's in bed 18 to 22 hours out of the day, she doesn't stay awake during meals. She went from three meals down to one meal that she just picks at.
Those are the features that you're looking at to prove that decline or there. And you're really telling a story. 
Alex: Are there, like recommended or official scoring mechanisms to track this sort of decline or is it kind of the lib as you just described? 
Guest: You know, you're really speaking to whatever their terminal diagnosis was [00:53:30] and you can add other features too.
but if somebody comes in with. Congestive heart failure. There are features that you're looking at that are there showing that the congestive heart failure was really starting to take over. If you have a patient who's on work for a cancer diagnosis, there are features around that and measurements and, scoring that would, that would speak to that.
And that's what you're really showing is that, you know, due to this diagnosis, this patient is experiencing these [00:54:00] declines and, and like I said, other things maybe come into the picture as well, that aren't necessarily associated as a direct line to that diagnosis. Cause there's probably a lot of comorbidities.
That are, that are working in this, in this factor as well. 
Amy: And I wanted to add to that, and then push it back to Kathy for one really clinical, granular thing. But a lot of this is very, it's not subjective, but it's like objectively subjective. Like they seem to be declining is not okay. But like it is.
[00:54:30] Oh, you know, they're only eating 30% of their meal or, you know, that is like a weird, guesstimations a lot of guesstimations sort of do, do impart onto, onto the judgment, but can you speak a little bit to mean arm circumference as a sort of a across the board way of measuring nutritional decline? 
Guest: Yeah. So meaner I'm circumference is something that we try to do, almost at every visit, but definitely around the certification visits.
And it's measuring, I'm gesturing for those who can't see around the middle [00:55:00] part of the bicep, on, on, usually on the right arm. But if you're going to pick an arm, make it be the same arm, and you measure that and, and as a person loses weight, you can start to notice that measurement and people will say, well, why are you measuring that?
Put them on a scale. Well, when you're at home, We don't have bed scales. And when you're at home, a patient who's bed bound is not very easy to get up onto your slick little bathroom scale, that you stand up on. So this is a way that we can show through measurement that a [00:55:30] patient's losing weight. but in, in its most extreme people can be down to really skeletal.
conditions. And that that number is not going to change because there's, there's nothing there to them anymore. 
Amy: I mean, you can comment on temporal wasting. I mean, there's all sorts of ways of documenting nutritional decline. Yeah. But Mac is sort of a very nice quote unquote objective one, even though it has a huge subjective component, because it may not be the same person doing it every time, but it might, and they may not have put it in the exact same [00:56:00] place, but they might, and they may have, you know, made the little tape measure a little tighter.
But they might not have. So there, there is some variability there, but it is an objective subjective thing 
Alex: who is making the recertification assessment. Does it have to be a, like a qualified healthcare practitioner, like a physician, or can it be a hospice nurse? 
Guest: It's kind of there it's the two together.
So because the nurse has been out making those weekly visits, they're the one who usually has all that assessment data and brings it to the physician. And usually we'll make that [00:56:30] face to face, visit with the physician and say, what you're seeing now is this. Let me tell you about how it has been, you know, how it was a week ago, a month ago, two months ago.
And that helps the physician write up that recertification statement based on what they're seeing in that moment, but also based on, you know, what the documentation has been up to that point. 
Amy: So, but you didn't Annette, but hold on, Alex, I want to clarify, this is not the, this is not the physician who has recommended hospice.
This has to be the medical director that is an employee of the hospice who [00:57:00] sits in the. Biweekly IDT meetings is actually making that assessment. So a hospice by just definition has to have a medical director and that medical director ultimately makes the final decision for whether or not somebody gets, recertified on a, on a, certification period by certification period basis.
It's not the nurses not making that decision nor is the quote unquote primary care doctor. And I'm using my little. Fingers here because you know, sometimes the primary care doctor does not take any responsibility for that patient once [00:57:30] they come onto the hospice service. So really the it's really completely up to the hospice to decide within the Medicare regs for each specific terminal diagnosis as to whether or not somebody gets quote unquote re certified on a, on a certification period by certification period basis.
Guest: Okay. So 
Alex: that was actually, that was actually my next question. Like typically when patients enter. Hospice are they usually giving up their relationship with their primary care doctor? And when you say the face to face with the physician, does that mean the [00:58:00] hospice. Medical director is driving around mostly to like each person's house to do the actual physical face to face, to recertify them.
Amy: So the answer to your question is depends on the size of your hospice, but if you have a small hospice and your hospice medical director is the only person who is either an NP or a M D on staff, then the answer to your question is, yep. If you are more robust and have a, you know, a larger hospice and can employ a nurse practitioner and must employ that nurse practitioner, like they [00:58:30] must be employed by the hospice.
They can make those face to face visits. PAs, we do not have, sorry. Physician assistants do not have the ability to do that under the hospice benefit at this point. 
Alex: Earlier, I don't know if you've misspoken, you said a nurse could be the 
Amy: medical director. No, a nurse practitioner can not be a medical director, but they can do face to face visits and nurse practice.
So the people who can do face to face visits are MDs or NPS. And that has to be done, you know, X amount of time before the next certification period, [00:59:00] blah, blah, blah, and a medical director can do the face to faces. Or an NP can do the face to faces, but an NP cannot be a medical director of a hostel that's 
Alex: right.
Has Medicare relaxed the face to face rule during COVID-19 to allow it to be done virtually or no? 
Amy: Yes. So a face to face visit can now be done by an NP or an MD virtually. 
Alex: Yes. I presume that's a temporary relaxation, as far as we know, 
Amy: we don't know it is [00:59:30] currently under the COVID-19 emergency stuff, but yeah, we're hoping it will stay like that because it's a very, very, time consuming.
Visit that often has no specific goals other than to kind of like draw, like if you could just drive by the patient's house for some of them, you just know they're declining. Cause you've been sitting in the IDT meetings, but it does afford the agency a way to like, you know, put, put your face back onto the, you know, the family and the family's sort of.
You know, you know, spectrum of, of, [01:00:00] of what they perceive as excellent care. And, you know, you do a lot of things when you are at that face to face visit, or that are not specifically the face to face visit, but it is, it can be very burdensome actually 
Alex: in order to become a hospice patient. Must you be in a, do not resuscitate status?
Guest: no, you don't have to be, what. But again, it's an opportunity to have a conversation with the family and the patient, about what [01:00:30] resuscitating this patient would look like. honestly, and, and sometimes graphically, what it would look like to try to resuscitate this 95 year old patient who has, you know, X number of comorbidities.
And you talk about the realism of that, you know, and what that would go through. And if, and if, you know, we started CPR on this patient. And we called nine one, one for them to go to the hospital. They'd have to come out of hospice as we spoke about not being able to really double dip those benefits. but then what that [01:01:00] hospital course would look like.
So an opportunity for the hospice team to really understand where the family and the patient are in their minds about. About this patient and what the trajectory for that patient looks like. and it's an opportunity to educate, but no, they don't need to be a DNR. for that, if a 
Alex: patient or family member.
Declines to be in DNR status. Is that a signal to the hospice that this might be a difficult [01:01:30] patient or family or somebody who doesn't really understand the purpose of hospice or, or can that patient still be like a really good patient? Not just clinically, but also business wise for the practice. 
Guest: You know, honestly, it's not going to be that conversation that tells you that this patient is not, the family is not on board.
That's not the red flag. That's going to be one of many things. When a, when a family is feeling like they have to be in home, especially they've been brow [01:02:00] beaten into hospice when really it is the appropriate decision, some of them kind of come kicking and screaming. usually it's the family. It's almost never the patient.
the family really. has a hard time getting their mind around hospice and, and allowing for natural death and coming to terms with what's happening with their loved one in an, and that's what it's about. It's about this grief, this unmet grief that they are, haven't dealt with about the thought of losing this patient.
And so it's an opportunity for us to bring in that bevy of, of team [01:02:30] members that we have to deal with social work and chaplains to talk to them about. You know, dealing with that grief and understanding what what's unresolved about them losing this patient. And obviously that's, that's not an easy thing to talk about, and it's not a, a light thing to dismiss in a family and an, a dynamic.
but the DNR is just telling you that, you know, that's, it may be a DNR that's been there for a long time. And when you sit down with a family and you say, look, when this, this is, this is how it's going to play out. If, if, if your mother's heart [01:03:00] stops. Would you like us to perform this procedure or call nine 11 and have people come and perform this?
you know, oftentimes very violent and very, damaging procedure to an older body. That's that's already compromised. This is what it will look like on the other side, you know, what do you, what do you. What would be your goal in her having CPR, because you think that it will prolong the days and weeks that you'll have with her?
Well, this is what those days and weeks would look like. And then people [01:03:30] say, Oh, well then I guess, you know, maybe not, or they'll say, can we just leave it on about it? And then as you have them on hospice, more often than not people understand and yeah. And start to come around to the idea of what's happening with their patient.
And honestly, the DNR, sometimes something that's just forgotten about. Because they understand and they see this, that their loved one is comfortable. They are understanding that this is, you know, not as scary as it seemed at the beginning. they've had a lot of questions answered. They've had a lot of [01:04:00] time to kind of come around to it.
Alex: Yeah. I think if somebody recorded a real live video of an actual resuscitation attempt in the ER, you know, and blurred out the patient's face. If we, if family saw what actually happens and how excrutiatingly painful and messy and bloody these resuscitation attempts are, but that video could probably do more to change people's minds [01:04:30] than any amount of conversation.
Amy: I completely agree with you. Absolutely. I mean, I think so I'm just, you know, giving people real life data about what the survivability of, you know, do you want us to break all of the ribs and sort of essentially harmed them on their way? To almost definitive death like that, that's sort of the, the critical piece here is that everyone thinks, well, if they do it, then you're going to survive it.
No, no, no. If you do it, you're, I mean, it's fractions, you know, you [01:05:00] know, 
Alex: and it's not just survivability, it's meaningful survival, 
Amy: right. When there was, when, when their, when their baseline state may have been really compromised. Alex, I want to go back to some of the other sort of pain points that, families not only just have, Brown.
You know, DNR and, and, and in most polls, that type of stuff, but the other things, yeah, they're often hard for families to accept about accepting hospice, include. So you're saying, you know, people will say, so you're saying I can't go back to the hospital. So you're saying I can't go back to the hospital.
I mean, that's really [01:05:30] semantics. Well, of course you can always call nine one one and go back to the hospital. You will just not be able to be on hospice at that time. Cause you can't be double-dipping. So there's that the second thing is, well, what about all of my expensive medications that I'm taking for X, Y, and Z?
Are you going to take those away from me? And so I'm going to tell you, there are some rules and laws coming down the pike in 2020, 20, 21 that are going to speak a little bit to this, but as Kathy and I know one of the issues about, coming onto hospice is that [01:06:00] there have to be choices because hospice is a part, a benefit.
And as part of the part, a benefit, Medicare. Insist that we cover all medications as they relate to symptom management and for taking care of somebody in there for their terminal diagnosis. there's always questions that come up about insulin for diabetes and, and, you know, thyroid medication and stuff like that.
But there's often very expensive medications that people have been on for years and years that do not make sense for. The hospice to cover under [01:06:30] the Medicare part, a benefit. And so, depending upon what they are part D D as in dog may pick them up, but they also may be. Having to pay for parts of it out of pocket.
So that becomes a friction point. and then of course, sort of, Oh, well, if I get dehydrated, you'll come in and put IB fluids in, but there's a lot of data to suggest that that actually can cause more pain and suffering at end of life than it does provide the family with being like, well, at least she didn't starve or, you know, dehydrated.
So I would say like, those are the big ones is DNR status. [01:07:00] I can't go back to the hospital. That's expensive medication. And then Ivy fluids, those kind of keep coming up as. Big sort of friction points for people being willing to accept hospice. It it's all about communication. And it's all about making sure that your nurses feel able to have those conversations.
Guest: So 
Alex: as an ER, doctor, my most common, encounter with hospice patients, I believe, would be trauma related. You know, hospice patient is a, you know, colon cancer patient and they're dying and they [01:07:30] have a trip and fall and now they have a hip dislocation. Or a massive gash and they just need the ER doctor to like pop the hip back in or, or, you know, sew up this huge cash.
talk to me about that. Like how often does something like that happen? How big of a problem is that? And you actually have to, I guess, switch them out of hospice status to deal with that acute issue. 
Guest: What are your thoughts? That depends too. And that depends, On the hospice operations too, because that's dollars as well.
you know, we tell [01:08:00] patients, you know, it's not that we don't want you to call nine one one it's that we'd like to be part of the conversation because what you may call nine one, one for, we may be able to come out to the house and help you with, without. You know, setting off all the bells and whistles of a, of a nine one, one ER, visit.
So if somebody has had a trip and fall and there has been some sort of trauma, a broken arm, a broken hip, some sort of fracture, you know, of course we want to get that set. We want to have, we want to make sure that patient [01:08:30] is comfortable and, you know, getting that care that they need. But if the, if it's going to involve, you know, a hip surgery, then we probably want to put them out of hospice in order for them to get that care.
If that's how they'd like. Now some families will say, I really don't think that mom or dad is going to, really, do well going. And a lot of surgeons maybe won't even touch that patient because that patient may be so, you know, so, so beyond. an, a safe place to be able to endure a surgery, like a, you know, [01:09:00] a hip replacement or a, a fracture.
A reduction. And so we would have the hip set and maybe we've had patients be in traction at home so that they're comfortable. we've done that before. It's just, every situation is different and, and truly every patient comes in with, a new combination of questions and what ifs and, and you just kind of deal with those as you come.
Cause you have to look at. That whole patient independently and all of their, you know, [01:09:30] pros and cons to figure out how to provide them the best care. 
Alex: What are the most common reasons that a patient leaves, ho hospice status? Is it trauma related or is it something else? 
Guest: I would say it's not trauma related.
the number of times that we've seen true trauma with a fracture or some, something like that, that can't be managed at home. If somebody falls and has a gash, a lot of times we can handle that at home. I'm doing wound care and, and something like that, that the reasons we see people leave [01:10:00] hospice, When they're not being recertified because they're not declining, but we see people leaving hospice.
because honestly they probably weren't in. Totally on board with hospice to begin with. So at the first sign of a crisis, in terms of that patient is starting to have shortness of breath or that patient is having pain, or maybe they've stopped eating, something. So there's been some change in the patient's condition that the family member has gotten scared [01:10:30] and may think.
Maybe, you know, this is something that they can fix, that we can go to the emergency room. So we'll get those phone calls. half the time you can say to the patient RA, well, let's try this medication to help with the shortness of breath or let's put some oxygen on and I'm on my way and I'll be there.
And we'll assess when I get there. the other half of the patients say the ambulance is here. We're taking them to the hospital. Can you meet us there? And then you, you deal with that as you get there. But most of the time, I would say Amy, would you agree? It's it's mostly [01:11:00] a family member feeling scared.
Amy: Yup. Yup. I mean, I think that, you know, when you look at assisted livings, oftentimes it's failure of the staff to understand if a patient's on hospice. Forgetting that they're on hospice. They are panicking. They don't want to be held responsible, not understanding how to deliver the medications. I mean, there there's a, there's a huge skill set in assisted living.
It's like small group homes are often different than large group homes in terms of how they handle hospice, because, you know, in, in a larger assisted living, the hospice nurse who comes into [01:11:30] round on her, Or his caseload that's in that hospice will have, you know, hospice, hospice, hospice. The patients will be very clearly identified as hospice patients, but I have been in small group homes or even smaller assisted livings, where if something happens to the patient, everyone panicked and they just call nine one one, cause they don't know what to do for patients who are living at home for whom they are.
Caregiver is primarily their family member. you know, people just worry. They like, they suddenly, they, they question everything about the decisions that they made on hospice. Sometimes, you know, if there was [01:12:00] sort of this question, maybe the, maybe one brother was there, maybe the daughter who, you know, wasn't always really on board, but was willing to be there to help with it bathing and some medication administration.
It really. Varies a lot. I mean, the whole goal is to put the hospice number everywhere you possibly can. If in case of emergency call, this number hospices are available 24 seven, and they really do replace pretty much every other form of care that that patient was [01:12:30] receiving up until then. You know, they become, they become a resource manager, you know, they, they basically are the front door to healthcare.
And that's what you want to encourage, from your, your pay, you know, an understanding of from your patients.
Alex: I had another question. 
Amy: I know your next question was when, w w w I guess the next question is why. Are physicians not understanding hospice. [01:13:00] Why do primary care doctors, oncologists, cardiologists, pulmonologists, all the ologists. Why are they not referring to hospice earlier? Why are we seeing so many less than seven day admissions?
Why do we, you see less than 14 days? Why isn't, why aren't people able to take advantage of the hospice benefit earlier? I know why that's such a great question, Alex. I just want 
Alex: to have heard that listen to our podcast yet. 
Amy: Well, I mean, well, you know, having been an ER [01:13:30] doctor and then having been this sort of version of a primary care doctor in the form of a house call doctor, I'm sort of floored at what either miss or non information is out there.
As an example, most primary care doctors do not realize that if you put somebody onto a hospice service and they meet the qualifications, you know, I mean, they don't have to understand everything about what the terminal diagnoses are and no one's going to come back to them and do a money grab from them.
If they refer to [01:14:00] hospice, there's this fear. I'm not saying on that piece of paper. Oh no. Oh no. Oh, I'm not . Nope. Like I'm not sure. Fear is on the part of primary care doctors to make that initial. Referral. Why don't you just make the referral and let the hospice agency decide if that patient qualifies?
Because they're ultimately the ones that have to decide the medical director and the admissions nurse have to decide. Do they meet the qualifications based on a certain terminal diagnosis? If the answer is yes, let the patient decide that the. Primary [01:14:30] care. Doctor can also be like, you know what? I actually don't want to be that person's primary care doctor during this hospital, this hospice certification.
And oftentimes the hospice medical director will become the primary care doctor for that patient. We don't want that because of course you want to have people continue that relationship. And it's really important. But if you know Mr. Smith, who's, the patient has met, you know, dr. You know, Jones one time.
You know, I could see how dr. Jones would be like, you know, I don't really, this is not a [01:15:00] relationship that I feel is going to be additive to this person's hospice experience. 
Alex: I w I, I don't understand how a primary care doctor could continue to have a relationship if they can't build a patient. 
Guest: Well, well, that's such a great 
Amy: question cause it's not all about the cash money.
You know, sometimes it's about dr. Jones has known mr. Smith for 20 years. It all makes sense. You know, why it's the only billing code. That dr. Jones could [01:15:30] still bill for taking care of mr. Smith is actually care plan oversight. So if you are somebody who keeps signing the hospice documents month after month, because the patient's on hospice, every time you do 31 minutes of signing documents, talking to the hospice nurse, you can bill about $125 a month for the care of that patient.
Alex: Oh, so, Oh, 
Amy: now it makes financial sense. 
Alex: Okay. Well, I think most doctors probably don't know about it. 
Amy: They don't know that. Correct. 
Alex: So even if the patient, [01:16:00] let's say if your patient transitions to hospice status 
Amy: yep. 
Alex: You, the primary care doctor who normally builds part B Medicare can still bill yeah. Care plan oversight, and your responsibility would be to oversee the care plan and sign.
Amy: What. The, the, the random pieces of paper that go flying their direction, which is like, just as an FYI, we had an IDT meeting and here's what we did. 
Alex: And if they do that, then they would be the ones who would be recertifying the patient, not the medical [01:16:30] director or no, 
Amy: no, they just, it's a weird relationship, right?
It's, it's, it's so complicated because Kathy and I redesigned our front end paperwork several times to kind of accommodate the weirdness of all of this, which is. If you're a primary care doctor, the relationship you have with the patient on hospice is really weird. It's Hey, do you want to sign their death cert or don't you want to sign their death?
Cert, do you want to know what's going on with the patient or do you not want to know what's going on with the patient? [01:17:00] Will you sign these pieces of paper? Will you not sign these? None of them are like make or break. It's almost like we're welcoming that person to continue to be part of the conversation, but not to have any.
Not ultimately to have any decision making powers. It's really just, Hey FYI, you're the primary care doctor. If you want to be the primary care doctor that continues to know about this patient, we're going to make you sign some pieces of paper. That basically just say, I acknowledged that this is happening.
It, if you decide not to sign them, guess what? [01:17:30] The medical director will probably sign them anyway. And they will switch the primary care provider to the medical director. It is really just a way of continuing to, honor the relationship that that primary care doctor had with that patient. So many doctors just don't want anything to do with it.
They don't understand how you, Oh, there's even one further question, which is, Hey, in the middle of the night, do you want us to call you about morphine? Order changes. There's some doctors that are like, I want to have total control. I want to know everything that's [01:18:00] happening. Please don't change morphine or add.
I mean, I don't know who this crazy people are, but there are exist. They want really a lot of control. And then there's some that are like, Oh no, no, just call me when the patient dies. So there's like a whole menu effect of how that person can continue to have a relationship with that patient. It's really kind of weird.
So. But if you continue in any capacity, you agree to continue being that person's primary care doctor, you will get pieces of paper, where to sign that basically acknowledge that you understand what the care plan [01:18:30] is. And then you can bill for care plan oversight. If, if you so understand how to do that under part B.
We 
Alex: probably need a separate episode just on this side. Yes. I think, I think for doctors 
Guest: reasons 
Alex: there were two or three reasons they don't do this. One is they just don't know and understand number two. So there's this kind of fear of what I don't know. And making a mistake and incurring the Medicare audit.
Yeah. And second is difficult conversations. They don't want to have difficult conversations with patients, families about why did you recommend hospice to my [01:19:00] mom? You know, screw you a bad doctor. 
Amy: Well, yeah, well, that's what that's my Yelp looks like, by the way, you want to know if you wanted to know what, like people's Google reviews are like dr.
Schiffman recommended hospice booze, you know, like that kind of thing. But, but you didn't mention number three, which is EMR is, are not set up to manage this billing code. Right. Cars are not set up to manage any time based billing. So like you can't just be like, Oh, it was a level three visit, great, nine, nine, blah, blah, blah.
But this one's like [01:19:30] a G code and it depended on an additive amount of, you know, minutes that you spent over the course of a calendar month. And you know, you then, but you can't do it. If it excludes it. If you're doing chronic care management, you can't do that. Like, it's just. Okay, sorry. 
Alex: I have one last question before I develop a deep vein thrombosis.
Guest: So 
Alex: if a hospice, patient or family calls nine one one and takes the patient to the ER, and let's say they didn't call hospice and the [01:20:00] hospice finds out like hours later, to what degree can the hospice agency retroactively? Take the patient off of hospice status in order to not incur the fee of the nine 11 and the ER, and all 
Guest: that, you know, sometimes we don't find out until the nurse doesn't get anybody to answer the door when she goes to make her visit.
You know, there have been all kinds of experiences where, where they just forget to tell them hospice. and that's [01:20:30] fine. So then the nurse will come with paperwork to discharge the patient and we'll, and we'll put the discharge date as the date. They went to the hospital. and then that will be the, the, the, the end of the period, their benefit period.
And that will. That we'll we'll solve that problem with the retroactive. But, I think one thing that we haven't talked about that I think is really important, too. And it's something that people ask about is, what happens if they don't qualify for hospice at one of these recertifications? [01:21:00] You know, if a patient, has been admitted to hospice and let's say they start gaining weight, or they, aren't declining just plateaued with their, with their symptoms, then those, then that's why that visit from.
The physician after the face to face. That's why the nursing assessments up to that point are so important because there'll be planning for that patient's discharge. And so that's not something that happens, out of the blue. Yeah. And then all of a sudden the family gets a phone call by the way hospice is ending.
Thank you very much. Have a nice day. [01:21:30] So that's something that our, the team will come in and say, listen, it looks like we might be discharging your loved one from hospice. And then the hospice will work to set that person up. On the outside of hospice, with the things that they need, making sure that they're reconnected to their primary care physician, making sure that.
If they need oxygen or that hospital bed, there are ways that we can work with that. And usually we want to put them back into some sort of care, like home health, something that will be [01:22:00] supportive because honestly we would expect that maybe in the next three to six to nine months, that patient would be back to us in hospice again.
So we keep them close. But we can no longer bill for them in hospice because their, their condition has changed. And we call that graduating from hospice and that's, sometimes around 10% of hospice patients do end up graduating. 
Amy: There's so much to talk about with hospice. I literally, okay. Kathy's coming back.
I made an executive decision. 
Alex: This was really 
[01:22:30] Guest: awesome. 
Alex: I love doing deep dives and Kathy, this has been tremendously informative and helpful and just amazing. Fantastic. Thank you. 
Guest: Thank you so much. I love talking about this. I really do. 
Amy: So what's our website name, Alex. 
Alex: Thanks everybody. Mastering Medicare dot nets.
you can find this there. We love doing deep dives in the healthcare and elder care and payers space. so if you want to reach out to us, email us it's [01:23:00] amy@masteringmedicare.net or alex@masteringmedicare.net. We have a Facebook group. We have a med mastering Medicare cheat sheet. Just let us know, reach out to us.
We love hearing from our readers and listeners and Watchers. Kathy. Thank you so much for thank 
Amy: you so much, Steve. 
Guest: Oh, 
Alex: informative. I love it.