ESRD & Hospice Care: The Cost of Dialysis

Hospice care for patients with End Stage Renal Disease has always been tricky. To qualify for hospice under the ESRD diagnosis, a patient has to have a creatinine of 8.0 or higher, which typically does not occur while someone is still on dialysis. Most often, the admission of ESRD patients to hospice programs occurs when the patient chooses to opt out of dialysis.

For patients who are on dialysis but have other comorbid conditions, things get even trickier. While new proposed guidelines have not yet gone into effect, CMS started pushing these issues back in late 2012. CMS insists that if any comorbid conditions other than the hospice admission diagnosis are present, it's up the provider to "prove" that the secondary diagnoses are not related. In the past, CMS did not consider comorbid conditions for the admission to a hospice program. As a matter of fact, because of this, most hospice companies did not employ coders or billers like other healthcare providers do. Their billing was simple, because the patient was admitted for one primary diagnosis only, and no other coding was required to submit a bill to CMS for payment.

As some diagnoses, like "debility" and "failure to thrive" were increasing in use, CMS started taking a much closer look at the eligibility of these patients, and others, for hospice care. At that time, CMS realized that because they did not require secondary diagnosis to substantiate a hospice-eligible diagnosis, they could not evaluate "what was related" and what wasn't.

• It was widely known within the hospice community that a "debility" diagnosis was non-specific, and therefore the hospice was responsible for all care. However, these patients had a higher rate of live discharge and longer lengths of stay.
• For a “Failure to Thrive” diagnosis, patients also lingered for long periods of time but unlike debility, the hospice provider was not responsible for the majority of needs these patients had...so, after much investigation, the rule was changed to move these two diagnoses to “secondary diagnoses” and to push for clarification through documentation of all co-morbid conditions that could be related to the hospice diagnosis. This rule put a huge burden on hospice providers, because they found themselves looking at much higher costs to care for each patient due to increased responsibility.

ESRD has many co-morbidities for most patients. Trying to determine what is related to the terminal diagnosis of a patient on dialysis and what is not is very difficult. If a patient has cancer, that's pretty cut and dried; ESRD is not related. However, if the patient is dying from heart failure—regardless of whether the heart failure was diagnosed prior to ESRD—it can be very difficult to separate the two. Most patients with ESRD had a long progression to dialysis and many, many studies demonstrate declines in cardiac function even before dialysis is initiated, especially if kidney failure occurred due to hypertension. For patients with genetic diseases, the diagnosis of the underlying condition will always precede any other diagnosis, making it even more difficult for a hospice provider to claim that ESRD is not related. Even patients with end-stage dementia could be subject to inclusion of ESRD as the underlying cause.

For these reasons, more hospice providers are opting to NOT admit patients with ESRD—unless they stop dialysis. As we all know, dialysis is extremely expensive, and the Hospice Benefit states that all treatments related to the hospice admission diagnosis must be covered by the hospice. When hospices are only paid $150-180 per day to cover Social Workers, Chaplains, Nursing Assistants, medications, supplies, medical equipment, dietary consults, physical therapy consults, and 24 hour a day RN coverage, you can see where it would not be financially feasible for a Hospice company to admit dialysis patients.

This is not new...we've been dealing with these issues and the way hospice is paid for years, but it's wrong and there should be some changes. In the end, patients with ESRD and their families benefit from hospice care at the end of life, regardless of the terminal diagnosis—and should not have to deal with barriers like this that may prevent them from receiving that care. Financially, it's CMS that benefits most, because they are no longer responsible for paying for dialysis. I think they have the bigger burden of proof that the inclusion of secondary diagnosis to establish what's related and what's not is more the to the benefit of the patient and not to them. As of now, my thoughts are that they are more concerned with their bottom line and that's a sad situation for dialysis patients.

Here are some examples to further clarify the problem:

• Patient A is on dialysis due to a longstanding history of high blood pressure. He was also diagnosed with Early Onset Alzheimers 20 years ago. The admission diagnosis to hospice is Alzheimers, and because the ESRD is due to high blood pressure, there is no relationship to the Alzheimers diagnosis. In this situation, the Hospice would NOT be responsible for dialysis. The patient could receive hospice care for the terminal diagnosis AND continue with dialysis.
• Patient B has lung cancer. She was diagnosed 5 years ago and went through multiple rounds of chemo; 3 years ago, she developed ESRD and started dialysis. In this situation, there is a high likelihood that the chemotherapy caused the ESRD, in which case the hospice WOULD be responsible for the dialysis. However, most people with terminal cancer will not opt to continue dialysis once they've started hospice care. If she chooses to stay on dialysis, the hospice provider would have to do a cost/benefit analysis to determine the feasibility of admitting the patient, due to the high cost of dialysis. Sometimes a hospice will choose to admit, because in all likelihood, the patient will pass quickly due to the cancer. A hospice will also admit these patients with the knowledge that in a short period of time—say days—the patient will be too ill to leave home for dialysis. It's sad that we have to think about this, but it's true.
• Patient C on dialysis wants to stop treatment and enter a hospice program. The hospice would not be responsible for dialysis.
• Patient D is on hospice for End-Stage Dementia and develops renal failure due to chronic dehydration and poor nutrition...both known issues with End Stage Dementia patients. The family opts to have her dialyzed. The hospice would be responsible for covering dialysis, however, more often than not, a dialysis company would discharge this patient for "noncompliance" with the Plan of Care or "going outside the Plan of Care”. This is sad, but may be the only way for some hospice companies to manage this patient, due to the high cost of dialysis.