"Rightly or wrongly, most people associate hospice with, 'You're going to die.' And some families are not very eager, or are even reluctant to make that decision quickly," he says. The timing of 24 hours, and the rush to designate hospice before the clock strikes, is what bothers him.
I asked Harlan Krumholz, MD, who helped formulate the rule and its exceptions with the Centers for Medicare & Medicaid Services, what he thought. He called it "anti-measurement hysteria."
"There's no measure on earth that's going to protect against someone like that. That's a person who shouldn't be practicing medicine."
But Kupfer says shifts to more hospice designation have already begun. "From what I see, more of us are more aggressive in recommending hospice for some of our patients with more severe illnesses."
Until the mortality part of the incentive payment kicked in, here's what usually happened when a certain "high-risk-of-dying" patient, say someone in her 80s or 90s, came into the hospital from a nursing home, Kupfer says.
"She has Alzheimer's, strokes, atrial fibrillation, and a urinary tract infection and a little heart failure. The discussion with the family isn't, 'let's put her in hospice.' It's 'We don't think she should be treated aggressively, but we'll give her some diuretics and maybe an antibiotic. And if she turns around, we can send her back to the nursing home.' "
Without a hospice designation that day, if that patient dies within 30 days, she'd count against the hospital's mortality score, "even if the family did designate hospice care for her four or five days later," Kupfer says.