Hospices often face obstacles when it comes to determining the relatedness of medication and treatment to a patients’ terminal illness. Providers are reevaluating how they prescribe and deprescribe medications for patients nearing the end of life.
Hospices have come under closer scrutiny in recent years as the U.S. Centers for Medicare & Medicaid Services (CMS and the U.S. Department of Health & Human Services Office of the Inspector General (OIG) continue to take a hard look at issues such as recerticiations and billing for services outside the hospice benefit, including medications. An increased focus on medication appropriateness comes with the new addendum to the election statement effective Oct. 1, even as the numbers of CMS audits are ticking upward.
Hospices now must provide Medicare beneficiaries with a written statement called a “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” detailing the conditions, items, services or drugs that are determined to be unrelated to their terminal illness and conditions and not covered by the hospice benefit. All patients admitted on or before the effective date have the option to request the notice in writing upon electing the Medicare Hospice Benefit. Hospices must issue the written addendum within 72 hours of a request made by the beneficiary, their representative, a non-hospice provider or a medical contractor.
Raymond Capella is the vice president of clinical and analytical services at Enclara Healthcare. With 15 years in the hospice and palliative care pharmacy benefits management (PBM) space, he currently oversees the client-facing clinical consultant and clinical analytics teams. In his role, Capella partners closely with hospice providers to manage direct and indirect pharmacy costs, provide strategic symptom management strategies and help hospice providers to navigate through industry and regulatory changes that impact their business and their care delivery models.
He recently sat down with Hospice News to discuss how hospices can better collaborate with pharmacies to improve the quality and experience of end-of-life care for patients and their families.
What are some of the current issues hospices face when it comes to balancing pharmaceutical needs of patients?
As we think about the hospice patients we serve at the end of life, the medication strategy is really to maximize patient comfort and use as few treatments as possible to allow that patient to transition in a dignified manner.
What they often experience is being prescribed more medications more often by more prescribers. You have basically this accumulation effect that’s occurring, this a prescribing cascade. Typically, these patients often have multiple comorbid conditions or other diseases, and that’s a recipe for a negative outcome.
From a hospice provider perspective, if you’re able to decrease the number of medications these patients are on, then they’re going to decrease some of their own costs as well. Deprescribing is about finding the most appropriate use for medication to achieve both goals of cost containment, as well as the positive patient outcomes and finding them comfort. Deprescribing is more of a systematic way of trying to simplify a hospice patient’s complex medication situation and also to align with the patient’s goals of care and really drawing the attention to symptom management and getting them as comfortable as possible.
What are the barriers that come into play in terms of determining medication appropriateness in end-of-life care?
The main one, and it’s a struggle that we have on a regular basis, is the communication aspect as the biggest challenge or barrier to medication appropriateness at the end of life. The biggest issue or challenge is that communication component.
It’s so engrained in most health care professionals, including pharmacists, physicians and nurses, to add more patient treatments to get more of a benefit. The challenge with the communication piece is really trying to flip that on its head to some extent to shift the care paradigm from curative-minded to more palliative-care minded. It’s difficult for health care professionals to have those conversations with patients and caregivers to understand what that means.
The ability to train hospice nursing staff and physicians even to have these conversations with patients and their families is probably the biggest challenge. The other thing you see in hospice unfortunately is a lot of nurse turnover where staff is brought in who don’t necessarily have a deep background or experience in hospice and end-of-life care. That turnover creates a challenge for these organizations trying to teach for retool prescribers to have those conversations and get out of that more curative mindset. Trying to achieve comfort and get the patient to the best state that we can doesn’t necessarily mean you add more things on.
The additional question for hospices is often coverage under the end-of-life care benefit. It’s not based on the diagnosis but rather the prognosis of the patient. If a medication is stopped and it causes increased or negative effects that the patient would experience through the remainder of their care, then hospices should consider that medication as a covered item. If the patient were to stop it, that would cause a very unfavorable transition and not a good death.
What are the financial impacts of polypharmacy on hospices?
The cost piece is twofold. First, if you think of traditional fee-for-service, pharmacy benefit manager-based arrangement, patients that are using more medications are going to have more costs associated with providing those medications. There’s a financial aspect for hospices that in some way incentivizes them to address polypharmacy.
The other probably bigger and even more financially impactful piece is more of the downstream, negative consequences. By overloading a patient on these large medication cocktails, you could potentially cause an adverse drug event. Downstream, you could have additional costs that you may not tie directly back to the pharmacy, but that are going to cost the hospice providers. The biggest cost is not always directly connecting those dots because it’s not as obvious as the cost of the patient’s actual medications. Hospices need to be thinking about why deprescribing is important in that financial sense as well.
What might be some of the potential cost saving opportunities of implementing deprescribing practices?
By deprescribing, you’re also mitigating risk of potential downstream issues by decreasing the toll that pill burden can take on the patient. It really comes back to more of a total cost of care reduction, where probably the biggest opportunity lies for the hospice organizations.
What might be some of the implications of the new addendum rule that took effect Oct. 1, 2020?
With the addendum, CMS has the intent to eliminate any type of confusion or anxiety related to the communication of what’s expected and what’s not expected such as medications or services provided. The addendum has really forced that conversation on the front end and made sure that it’s very clear to the patient and their family at the point of admission as to what’s going to be continually provided and what you’re going to stop. By forcing the conversation on the front end, it really started to bring to light the prescribing concept because now these hospices are forced to have those conversations, put processes in place and figure out how to empower their staff on having those conversations to successfully get patients off of medications as needed.
From hospice’s perspective, the addendum could also impact the referral base because it really draws attention to how well you can have these conversations with patients and families. Hospices have to be successful at identifying and articulating to families that particular medications are not going to help their loved ones anymore. The focus is more on comfort and pain levels, and that’s where the prescribing piece relates to the hospice addendum coming out now. Polypharmacy issues have always been there to some extent, it’s just forcing that conversation and forcing providers to be more efficient at managing that concept now.
How can hospices providers better collaborate with pharmacists? Why might it be beneficial to build a that partnership?
Unfortunately in many instances of health care, the pharmacist is often a missing piece of an interdisciplinary team and not incorporated as much. It’s very important to have a pharmacist included in that care conversation and speak about medications. There’s a lot of value in having the pharmacist input as it pertains to this and that care strategy, so there should be a relationship there to start off because they’ll have a unique perspective to add at the point of hospice admission.
The strategy for collaborating with a pharmacist for hospice providers is to make sure that the PBM vendor is assisting them with complete patient profile reviews and making sure that these pharmacists have tools and have resources available to do that.
By collaborating with the pharmacist you can have a better plan to wean the patient off of medications that have to be discontinued. It also helps in the family being able to see that as you’re slowly taking this medication away, there aren’t drastic changes to the patient.
It’s a unique strategy for the hospice to potentially be more successful with discontinuing patient medications and respond to any of the fears associated with that deprescribing.
What are some of the considerations of incorporating pharmaceutical services into interdisciplinary care teams?
Step one is involving the pharmacist and explaining what the hospice’s workflow involves, then identifying some challenges on the medication side where a pharmacist could help insert themselves into that workflow.
Enclara works with many hospice providers, and they all do things differently. We’ve developed best practices, whether formalized or more experience-taught. It often allows us to help identify a couple issues and offer solutions. Even if something hasn’t yet been identified as a gap, there’s an opportunity for the pharmacist to make some improvements in these medication areas that the hospice wasn’t even aware of. A lot of this goes back to communication and getting the hospice provider and pharmacist or PBM together to understand the workflow, identify what gaps a hospice might have, and also allow the pharmacist to identify where they think they can also add value or opportunity in that process for the patient.