“Outliving their profit potential”: hospice patients

Image by Ryan Stone, Flickr

“Hundreds of hospice providers across the country are facing the catastrophic financial consequence of what would otherwise seem a positive development: their patients are living longer than expected,” according to Kevin Sack in the New York Times.

The problem is the Medicare Hospice Cap, a law passed in 1982 to limit aggregate Medicare reimbursement to each hospice and assure that the average cost of caring for hospice patients was less than the cost of caring for them in acute care settings. The cap is determined by multiplying the number of patients by a per-patient allowance--$21,410 in 2007. When a hospice exceeds its cap, it must repay Medicare for services.

In the 25 years since the Hospice Cap was established, things have changed. Limitations on an individual’s length of stay have been removed, as long as a physician continues to recertify the patient as terminally ill. And those with non-cancer diagnoses became eligible. The two factors mean that the average hospice stay is considerably longer than in 1982: 86 days for people with Alzheimer’s disease versus 44 for those with lung cancer.

However, except for the yearly multiplier, no other changes have been made to the Hospice Cap.

In 1999, few hospices hit their cap. But estimates from the Medicare Payment Advisory Commission for 2005 project that 220 hospices in 25 states will be billed for repayment of $166 million. Most of these are independent hospices, and in some southern states, half of hospices will hit their cap.

In Wisconsin, 10-15 hospices hit their caps last year, according to notes from the May 2007 National Hospice-POE Advisory Meeting, Chicago CMS Regional Office.

Even with the increases in lengths of stay, hospice care saves Medicare money, according to Duke University professor Donald Taylor. And so the National Alliance for Hospice Access is calling for an immediate 3-year moratorium on calculating overpayments for 2005-2007, during which time Congress must develop a “fiscally sound, responsible, long-term solution.”

And if they don’t? To remain in business, some hospices have already begun to admit only cancer patients. Others, hoping to buy time, are “aggressively recruiting new patients in order to pay off last year’s cap charges.”

The next step may be to discharge patients who are medically eligible but just “live too long.” The Center for Medicare and Medicaid Services points out management issues behind that dramatic statement, especially doctors certifying patients too early.

Of course, you can’t tell the hospice story by numbers. Joan Rademacher’s end-of-life journey in the Wisconsin State Journal (May 2007) shows what hospice is all about.

Have you had an experience with the Medicare Hospice Cap? Care to comment on patients as “profit potential”—or anything else? Use the comment area or e-mail me at cmclaughlin(symbol for “at” here)milwagingconsortium.org.

Giving thanks: a work in progress

Today's blog is from Tom Thoreson, program coordinator.

I’m thankful that I have a family and community(ies) that support me for who I am and graciously receive the gifts we all share.

I’m thankful for the good health I have and the gift I am developing to provide guidance, direction and health to others.

I am thankful for the times in which we live. In many ways these are challenging times and the future can look quite bleak. Nonetheless, I feel much hope for our children and their determination for growth and development of ecological systems that sustain our planet. These are the best of times for many peoples that would not have had a voice in the past.

I’m thankful that I have chosen a path (sometimes it feels as if the path has chosen me) that guides me towards heights and depths and with a breadth I could only dream of. I’m thankful for those dreams.

I’m thankful for all of the teachers and clients and elders and youth and colleagues that people my days and nights.

I’m thankful for the mindfulness to be still and silent and patient.

I’m thankful for my thirst and hunger and curiosity and playfulness.

I’m thankful for this opportunity.

First Lesson in Magic

Everything you need comes to you.
The gift you didn't expect
is the other half of memory.
Use it whenever you need it.
Don't worry about why
you're different. The truth is
expect it. You're alive!

-Ann Filemyr

Are you ready for the aging workforce?

Looking around the room during meetings of professionals in aging, you’ll see many people, mainly women, of “a certain age.” People in their 20s, even 30s, are rare.

So when I read about the aging workforce, I think of us.

What, I wonder, are our own organizations doing to prepare for the future? For shortages and loss of skills and knowledge caused by our own retirements? What are we doing to attract and develop younger people?

Right now, I can't imagine not working--or not seeing the committed, still-passionate professionals I've come to admire in this field. But they tell me it can happen--will happen, one way or another.

The AARP’s Workforce Assessment Tool is a great way to take stock of the situation. It’s designed to help businesses “assess any potential impact the aging workforce will have on your organization.” It takes about half an hour to complete, and it generates a report of strengths and "opportunities." (That's "room for improvement" to those of us who predate the "no problem" era.)

It’s also a great way to look at the functions your organization performs, who performs them, what knowledge retention strategies you have, and more.

Some of the sections may lead to some corporate soul-searching. “Positive Work Environment” and “Workplace Accommodations” are two that might. So may “Training and Development Opportunities,” which inventories the types of training available to workers and whether the training is targeted to those over age 50.

Sometimes, we forget the need for lifelong learning in people who already have a lot of knowledge--or the desire for advancement even in people who may already seem advanced.

In looking at the “Flexible Work Arrangements” section, I was struck by how congruent the flexibility that appeals to older workers is to the flexibility younger workers—especially parents of young children—need.

Making a better workplace for older workers is making a better workplace for everyone.

Manpower, one of the Aging Consortium's member organiztions and sponsors, has some in-depth research on the aging workforce. You might want to look at New Agenda for the Older Workforce and Old Age Thinking, New Age Thinking.

Meanwhile, how’s your organization doing? Let us know your thoughts.

Time goes by

It's been difficult writing lately. This has been one of those times when so many friends and coworkers are dealing with illness and death that I can't help but see mortality everywhere.

About half of the daily alerts on aging that come over my desk have to do with looking good. Creams and surgeries, excercises to make people look and, I suppose, feel younger.

Not so much about growing character and spirit or finding ways to deal with loss. The misproportion of information frustrates me.

Then I came across a blog, The Elder Storytelling Place. It's part of the Time Goes By: What It's Really Like to Grow Older weblog. I'm going to bookmark Time Goes By; it's wonderful.

Today's entry, A second chance at life, is by Georgie Bright Kunkel, who at 87 is still a freelance writer and stand-up comic.

Her story isn't a laughing matter, though she reminds us that at $10,000 or more a month for life in a skilled nursing center, we could all retire to the Ritz Hotel.

It's about considering that her life will soon likely be the life of a single woman. But now, though she and her husband spent their 59th anniversary in the emergency room and he is now being cared for at $10,000 a month, for the moment, they have some precious time together. And the grace to know how precious it is.

And so I cherish the time spent with my partner, as un-private as it may be in our present circumstance. Even if complete recovery may not be possible, we have been given a second chance at living and loving and we must make the most of it.

And so I bring the crossword puzzle to share with my husband every day. I play on the keyboard that our granddaughter loaned us so that my husband can enjoy all the songs we sang in the nineteen forties. I throw the beach ball to my husband so he can catch and throw in order to restore his waning coordination. We kiss each other and whisper sweet nothings into each other’s ears, even knowing the room is bugged for health monitoring purposes.

No way will I lose this opportunity to partner with my husband. . .We still have each other. I don’t want to consider the alternative just yet.

There is so much pain and loss. But there is so much more. Maybe age lets us see the two together, teaching us to love more what we have to love right now.

“To be a person is to have a story to tell.”

Isak Dinesen said that.

And William Carlos Williams said, “Their story, yours and mine -- it’s what we all carry with us on this trip we take, and we owe it to each other to respect our stories and learn from them.”

Precious commodities, these stories.

You don’t have to be old to have a story. But being older means you’ve had a chance to accumulate a lot of chapters. You may have developed some insight into what the story means. And using experience or imagination or both, most people continue to work on that story until "the end."

If you know someone whose story you’d like to hear and preserve, there’s still a chance to become part of the StoryCorps project in Milwaukee.

Last January, the UWM Center on Age and Community partnered with the Milwaukee Public Library to make Milwaukee the first local “outpost” for this National Public Radio project in recording real people’s stories.

• StoryCorps will be recording in the Milwaukee Central Library Oriental Room until January 24, 2008. Log onto the site to register or call toll free 800-850-4406. You’ll get help—and a CD of the interview. With permission, a copy will also be sent to the American Folklore Center at the Library of Congress as well as the Milwaukee Public Library.

• On Tuesday, November 20, 7 pm, at the library’s Centennial Hall, you’ll be able to hear David Isay, founder of StoryCorps and author of a book about the project: Listening Is an Act of Love: A Celebration of American Life from the StoryCorps Project. The book contains some of the most compelling stories the project has collected. Call 414-286-3572 for reservations.

(Studs Terkel, who’s devoted a lifetime to telling the stories of real people, says the book "is history in the richest sense of the word, the kind that makes people feel like they count. . . This is what our country is all about." )