NHPCO President: Base Hospice on Patient Needs, Not Six-Months Prognosis

The person-centered, interdisciplinary care model applied by hospice providers should not remain cocooned within the six-month Medicare benefit.

This according to Edo Banach, who in 2017 after years of legal practice and government posts with the City of New York and the U.S. Centers for Medicare & Medicaid Services (CMS) took the helm as president of the National Hospice & Palliative Care Organization (NHPCO), the largest nonprofit membership organization for hospice and palliative care providers and professionals.

Banach recently sat down with Hospice News in Washington to talk about how hospice can evolve in tandem with the changing health care environment while remaining true to its roots.


You have called for more flexibility from payors and regulators in regards to the death-within-six-months prognosis. What would you like to see happen in that area?

The question of whether someone is eligible for hospice should be linked to their medical and nonmedical needs, and ‘needs’ does not mean six months.

A person with dementia, for example, may have the need for interdisciplinary person-centered care for a really long time. But when you focus on the six-month prognosis, the hospice is under tremendous pressure to discharge that patient alive. Then that person either returns to hospice or decompensates, goes into a hospital, then goes into a nursing home, and then comes back to hospice. And by then we have spent a million dollars for no good reason.


I would prefer to allow a hospice more flexibility to provide the care the individual needs at the appropriate time.

You have spoken about how hospice shouldn’t let itself be “boxed in” by the Medicare Hospice Benefit. With Medicare being the top payor and regulator for hospice, where can hospices find the flexibility and creativity to think outside that box?

Hospice should be careful to not let itself be defined by the Medicare Hospice Benefit. I think it is really important for hospice to think about how we can provide some of our services outside of the Medicare benefit.

One way is to contract with the entities that have been established by various [Medicare] demos. If you think about a local hospice that is operating under a waiver to provide more community support and reduce rehospitalizations, or you think about [accountable care organizations] or medical homes, they are trying to do the same thing: Provide preventive care that will help prevent people from needing more expensive care.

A lot of that care happens to be nonmedical care, supportive, interdisciplinary, that caters also to people’s spiritual and psychosocial needs — and that’s what hospice does.

You have spoken at NHPCO events about the evolution of the health care system, where does hospice fit in that process?

We are in this moment of evolution in the health care system where it is starting to catch up with hospice, with increased emphasis on access to nonmedical supports and services, person-centered interdisciplinary care, and addressing caregivers’ needs.

All of these are elements that in a way hospice has given to the rest of the health care system, and I think it is important for hospice to both take credit for it and then continue to evolve itself so that hospice can continue to be a beacon for the rest of the health care system.

What do you see as the next phase of evolution for hospice?

I think that for both hospice and for the NHPCO the first priority is always to focus on providing the best quality hospice care — however that’s defined — and secondly to provide person-centered interdisciplinary care earlier and for longer periods of time, because people need it.

My great aunt Ruby — who has [chronic obstructive pulmonary disease], but is not ready to say that she is imminently dying or have someone declare it — her only option right now is to call 911 or go to an urgent care clinic if her oxygen machine were to break, for example. There is a gap in the health care system that I don’t think hospitals, nursing homes, rehab facilities, skilled nursing facilities, or any other setting is actually addressing, that hospice is well-positioned to address.

The North Star is closing the gap that we see in the health care system, making sure that we have a continuum that takes people from the time they become seriously ill until the end of life. And that’s where we have been going.

When I was at a nonprofit hospice many years ago, we were doing community-based palliative care under contract with Medicare Advantage. These are not new concepts, but certainly we need to do it more and earlier, not just because it’s good for business, but because people need it.

To your point about providing earlier access to hospice, many have indicated that advance planning and earlier end-of-life conversations are a priority for hospices. How can providers advance those conversations?

This is best done before there is a crisis, before people are going down the trajectory where their illness is going to take their life, and I think Medicare has some things that they can do that can be very productive on this. For example they could require an earlier conversation about wishes goals and advance directives. The “Welcome to Medicare” physical and the annual physical are really good opportunities to do it.

Also, advance directives and any documented patient wishes regarding end of life should be digitized. It’s not enough for there to be a piece of paper in a lock box somewhere. If there is an electronic health record, it should be a part of the electronic health record We support all efforts to do that.

CMS recently announced new primary care payment models, for which they have released few details thus far. What would the industry like to see happen in regards to these models?

We want to make sure that hospices are indeed eligible, that CMS provides support, funds or both to ensure IT interoperability, and — above all — that any model utilize the person-centered, interdisciplinary approach that has made hospice successful for more than 35 years.

There is an ongoing conversation in the industry regarding the importance of service diversification for hospice. Why is this issue coming to the forefront?

Diversification is crucial. People don’t think in terms of hospice, palliative care, home care or personal care. Organizations need to provide the right support to the right people at the right time, and minimize clumsy handoffs that can serve to confuse and frustrate people. I would argue that the more patient-centered and interdisciplinary an approach can be, the better. This is where hospices shine.

What would you like to see happen in terms of a future payment model for palliative care?

I think it’s most important that a future payment model define with specificity what we mean by “palliative care.” It starts with the National Consensus Project which [NHPCO was] involved with, but I think we really have to boil this down to asking what is Medicare in the business of paying for. It starts there. There are a lot of things called palliative care, and they are not all the same, so we have to start with that standardization.

The second thing is that it needs to be linked in some cohesive way to what we call hospice. If all it does is establish a palliative care benefit that is different from hospice and different from home health, then we have just created another problem of people having to jump from one hoop to another hoop to another hoop in order to get the kind of care they need.

We want to see continuity between what we call palliative care and what we call hospice for the benefit of patients and families.

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