The United States is one year into the global COVID-19 pandemic, and the impact on hospice providers has been profound. Hospices have adapted to the realities of the public health emergency in ways that will continue to shape the care they provide as well as their business operations for years to come.
Last year almost to the day I wrote an editorial titled “Hospice Will Weather the COVID-19 Storm,” and that has largely been borne out. Hospices have continued to demonstrate their extraordinary resilience and extend their legacy of rising to any occasion. They have continued to provide quality care to a vulnerable patient population that often does not understand the work that they do, within a health care system that often doesn’t recognize the value that they bring.
However that does not mean that providers have come through unscathed. Many have endured, but few have prospered. Providers continue to wrestle with high costs for equipment and supplies, increased need for paid leave for staff and rising rates of turnover in an already competitive labor market.
Providers have had to find new ways to support their employees during a time of unprecedented personal and professional stress. Hospices leaders have encouraged their teams to have each other’s backs, established support groups, increased paid time off and instituted new employee assistance programs to help stem the tide of burnout, exhaustion and trauma.
Virtually every aspect of hospice operations have been affected. The pandemic’s impact extends beyond the clinical sphere. ”Back office” teams have adjusted to working remotely, sometimes with newly adopted technology platforms. New provider partnerships are forged online. Even mergers and acquisitions are no longer sealed with a handshake as the business engines of hospice shift toward the virtual space.
The above factors make for a murky future. During the pandemic, uncertainty rules. We can end almost any sentence with a question mark, and long-term implications are difficult to gauge. That said, examination of current trends can give us some perspective on where the industry is headed in what are hopefully the latter days of COVID.
Hospices have participated in a telehealth revolution driven by sheer necessity and a relaxation of regulatory limitations on those services. The U.S. Centers for Medicare & Medicaid Services (CMS) has indicated that it would review which of those flexibilities can be made permanent. Many of these apply across the health care continuum, but of particular interest to hospices is the ability to recertify patients via telehealth as opposed to an in-person encounter.
Regardless of the agency’s decisions about long term telehealth regulation, virtual care will remain a growing enterprise within hospice and palliative care. Providers are unlikely to abandon the investments they’ve made, the efficiencies telehealth has allowed them to create, or the benefits to patients that they have realized.
Providers have also seen a shift in their referral mix. As more patients and families seek to avoid institutional care to prevent risk of infection, hospices are seeking fewer referrals from hospitals and skilled nursing facilities while those coming from physician practices are rising steadily.
It stands to reason that institutions will rebound as more people become vaccinated and the pandemic relents, but those physician relationships are unlikely to disappear. Those connections are likely to benefit hospices in the long run and are helping many stay afloat as the public health emergency continues.
However, patients referred by institutions tend to have longer lengths of stay than those sent to hospice from community physicians, which has put pressure on some organizations’ bottom lines. Education for referral sources about the importance of moving eligible patients into hospice earlier is a paramount concern for the sake of patients quality of life as well as providers’ financial sustainability.
A side effect of public anxiety about entering hospitals and other inpatient or residential health care settings is that more care is moving towards the home. Bringing care to the home is a trend that began in earnest long before the pandemic, but the pace has accelerated — a boon for both patients and providers. The rate of change may fluctuate, but the future of home- and community-based health care looks bright.
Providers are also seeing a steep rise in demand for palliative care. With few therapies available to treat COVID-19, symptom management is a paramount concern. The psychosocial toll of the pandemic, including stifling isolation for many seniors, is generating a greater need for the spectrum of interdisciplinary services that palliative care provides. Overwhelmed providers in other clinical disciplines are in greater numbers seeing the benefits of palliative support and seeking it out for their patients.
This development underscores the need to fix the ramshackle reimbursement structure for community-based palliative care. Current payment models pay almost exclusively for services from a physician or licensed independent practitioner and often do not support the full range of interdisciplinary palliative care.
CMS does allow Medicare Advantage plans to cover palliative care as a supplemental benefit. Analysis by the consulting firm ATI Advisory found that the number of health plans offering home-based palliative care coverage jump to 134 in 2021, up from 61 last year. In-home support services, food services and social needs benefits also saw a substantial rise. All told, more than 1,350 plans are offering primarily health-related supplemental benefits this year. In 2020, the total was 635.
Despite this progress, these benefits are limited geographically to only 11 states for the time being, and the total Medicare population is substantially larger than those who opted into MA. The need for a dedicated Medicare palliative care benefit has never been more pressing.
Efforts have been underway among health care providers, state governments, advocacy groups and payers, among others, to make community based palliative care more accessible to patients and families. These are worthy efforts that hold genuine promise for expanding the availability of palliative services, but by their very nature they will not have the reach and impact of a coordinated, national program.
The resilience of health care providers, including hospices, have rarely been tested as they have during this past year. Their achievements are inspiring, but that reality cannot overshadow the degree of hardship that providers have faced. They still need help.
While most hospices have been able to hold their heads above water during this crisis, federal aid from the Provider Relief Fund and other programs have been key to their ability to stay afloat. The recent $1.9 trillion stimulus package fostered by the Biden Administration did not inject any new dollars into that program. LIkewise, the federal government has not yet extended the moratorium on payment sequestration beyond its current expiration date of March 31.
Continued aid for the duration of the public health emergency is an imperative to ensure that patients and families continue to receive the care they need during times of serious illness or the end of life.