Learning Activities

Word document

There are two suggested learning activities that might be used in-class or outside of class setting with students.

Activity 1

1. Ask students to visit the HFA or NHPCO websites and locate the hospice(s) nearest to where they live.

Activity 2:

Medicare's 'Failure-to-die' Rule

Ask students to read the following 3 articles from the Wall Street Journal.

Article #1:

1. Ask the students to divide into groups or as a large group and do a brief role play of one or more of the patient scenarios by acting out the patient, a family member, the hospice nurse and the hospice administrator roles.
2. At the end of the role-play exercise, ask students to discuss what their feelings were toward the different characters and share them with the class.
3. Discuss ideas to change this appalling situation.
4. Read articles #2 and #3 and discuss possible ramifications.

Article #1

Dow Jones Interactive® Publications Library

Rules Are Rules:

Hospice's Patients Beat the Odds, So Medicare Decides to Crack Down

Terminally Ill Who Don't Die Within a 6-Month Period Risk Losing Coverage

Al Ouimet's 9-Year Survival

By Lucette Lagnado

06/05/2000

The Wall Street Journal

Page A 1

(Copyright © 2000, Dow Jones & Company, Inc., used with permission)

PLATTSBURGH, N.Y. -- One day in February 1997, about a half-dozen ominous letters were delivered to people in the area surrounding this upstate New York town, 20 miles from the Canadian border. Under the bold title "Medicare Fraud Investigations," a company called United Government Services warned recipients that they were under scrutiny for cheating the government. The upshot: Each of them might owe the U.S. tens of thousands of dollars.

The recipients had several factors in common. They were elderly -- most were in their 80s and 90s -- and had been diagnosed as terminally ill. They had been treated by the local Hospice of the North Country. And most significantly, their lifespans had exceeded federal guidelines. Medicare rules allow the dying to get benefits for six months of care from a hospice, an agency that provides palliative care, usually at the patient's home. While extensions are sometimes granted, any longer survival can be deemed excessive and can trigger an investigation. The Hospice of the North Country, which also received a letter, was seen as a particularly notable miscreant -- "the most aberrant" of all the hospices in New York, says Joanne Houillon, who runs UGS's Benefit Integrity Unit.

Among the patients who drew scrutiny: Rosie DesParois, 87 years old and suffering from advanced breast and endometrial cancer when she entered hospice. Though doctors believed the cancer had spread to her liver, she was still alive four years later, and the hospice was still getting Medicare reimbursement of $88 a day.

Another patient was Beatrice Bates, admitted at the age of 89 with uterine cancer, anemia, hypertension, blood clots, shingles, gout and coronary artery disease. She had suffered a heart attack during radiation therapy, and a priest performed the last sacraments. Still, she survived for five more years. The mailing of the letters set off a chain reaction that no one foresaw. It sent patients and their families scrambling to find substitute care and deal with the prospect of reimbursing money most of them didn't have. It placed Medicare in an awkward conflict with a federal judge, who was stunned by the government's position. It forced the hospice to come to terms with patients who had been living under a terminal diagnosis for years, and screen new admissions far more stringently. And it ushered in a host of strange, through-the-looking-glass policies designed to let hospice staff avoid scrutiny over patients who live beyond six months and at the same time provide the compassionate care that is their hallmark. `

'You Are Not Eligible'

Every day, about two dozen dying patients receive visits from the staff of the Hospice of the North Country, a nonprofit group based in a white frame house in Plattsburgh. The hospice 's territory spans 1,700 square miles. More than half its patients are on Medicare, which rarely covers all the expenses, ranging from nurses' salaries to pain medication to bereavement counseling.

The hospice movement began in Britain in the 1960s as doctors realized the terminally ill are often most comfortable when they can die at home, cared for by people specially trained in their needs. To be admitted to hospice, patients generally forgo curative treatment, such as chemotherapy or surgery. Medicare has for years encouraged the hospice industry, in large part because it is less expensive than nursing homes or hospitals.

But as the movement grew in the early 1990s, so did evidence of fraud and abuse. Particularly galling were audits in Puerto Rico, where hospices improperly billed Medicare to take care of patients suffering from chronic ailments such as obesity or arthritis. Nationwide, the government found that Medicare had wrongly paid more than $83 million for hospice care, and turned to its intermediaries -- companies hired to administer Medicare benefits -- to pursue fraud and abuse. One of those intermediaries was UGS, a subsidiary of Blue Cross & Blue Shield United of Wisconsin. The company had been involved in the fraud inquiries in Puerto Rico, and the Health Care Financing Administration, which administers Medicare, had UGS turn its sights on other areas.

To screen for fraud, UGS relied in part on Medicare's six-month rule, which dates back to the 1980s and is a guideline rooted more in bureaucracy than in science or medicine. Officials at HCFA realize it can be tricky to apply the rule to real life. Robert Berenson, HCFA's director for health plans and providers, says: "We try to emphasize that not everyone has to die within six months; it is a judgment." Still, he says, doctors need "to know what the rules are, and that their best estimate of prognosis should be six months or less."

HCFA also was warned in late 1997 to crack down on hospices. "There has been less rigorous enforcement of the six-month prognosis requirement by the hospice industry, especially for various noncancerdiagnosed patients," says a memo from the Health and Human Services Department's inspector general, adding that HCFA should be "making hospice physicians more accountable." Across the U.S., hospices were asked to turn over volumes of records, and many were told to reimburse the government for care given to patients who didn't meet guidelines.

In Plattsburgh, UGS found that five hospice patients didn't fit Medicare's definition of being terminally ill. The company asked for reimbursement of nearly $450,000 -- the entire cost of their care.

The letters UGS sent were tough. Patients were told, "You are not eligible for the Medicare hospice coverage," and added that "Medicare will recuperate the money that it inappropriately paid." The letters closed with the words, "We apologize for any inconvenience we have caused to you and or your family."

Sarah Anderson, executive director of the hospice, was aghast. She sent aides scurrying to patients' homes to intercept the letters, but in some cases, they were too late. Mrs. Bates's daughter-in-law, Thressa Bates, remembers the day vividly. "We were quite horrified," she says. Mrs. Bates was "totally upset. She thought she would have to pay," as Medicare's attitude seemed to be, "You're supposed to die, so why don't you?" Charles DeLong, whose wife Floy, 99, suffered from heart disease and diabetes, also was taken aback by the letter. "I looked at it and I thought, gee, what is going on?" he says. His wife had already left hospice after surviving two years past her terminal diagnosis. "I couldn't figure out where the fraud came, my golly," he recalls.

Ms. Anderson realized that her patients couldn't reimburse Medicare, but if the hospice did, it would go out of business. About 70% of the hospice 's insurance revenue comes from the agency. Donations, including bequests from patients, made up more than a third of the hospice 's $1.2 million budget last year.

The patients UGS cited were well-known to hospice staff. Typical was Mrs. DesParois, a retired nurse who hated taking medicine and was terrified of needles. She loved the idea of spending her final days in her old house that she adored, tinkering in her flower garden, continuing her 70-year cigarette habit.

She had captured the hearts of hospice nurses, in particular Alice Ballard, who was in her late 70s. Mrs. Ballard visited several times a week and, with the rest of the hospice staff, worked miracles, recalls Mrs. DesParois's granddaughter, Cindy Queyor. She remembers how hospice nurses brought coffee and doughnuts, gently coaxed her grandmother into taking pills, even hand-washed her collection of antique teacups.

As the inquiry closed in, the hospice decided it had to force out Mrs. DesParois. She was 91, but was lucid -- and devastated. "She said, 'Alice, hospice has dropped me,' " Mrs. Ballard recalls. "I said to her, ' Hospice has, but I have not.' "

Mrs. Ballard continued to visit Mrs. DesParois, but without the resources the hospice provided, the sick woman couldn't remain at home, and she slid downhill. Her house was sold, and she could no longer spend time in her garden. Neither her granddaughter nor her daughter were able to care for her. So she was sent to a hospital, then a nursing home where she became almost unrecognizable. She had long been a small eater, but at the home she stopped eating almost completely. "She lost all that she prided," says Mrs. Ballard. Cancer spread to her pancreas and stomach. She developed gaping bedsores and was in agony. And on Sept. 16, 1998, Mrs. DesParois died, away from her home and the hospice staff.

`A Horrible Mistake'

As it turns out, the government's move backfired. Mrs. DesParois's nursing home charged Medicare about $150 a day, nearly twice the hospice 's fee. Shortly after the letters arrived, Ms. Anderson, the hospice director, sent UGS a request to work out a payment plan of $5,000 a month. She says she didn't hear back. Then she prepared letters asking the firm to reconsider its judgment. "I was kind of sure this was some sort of a horrible mistake, that they would read this and change their minds," she recalls.

The hospice staff rounded up records on Mrs. DesParois, Mrs. Bates and Mrs. DeLong, as well as charts on a woman in her 80s who, having suffered a stroke and heart failure, needed help being fed and getting dressed. Finally, the staff had to deal with the case of Al Ouimet, who had spent more than six years in hospice after surgery for throat cancer.

Mr. Ouimet personified some of the problems Medicare wanted to address. In 1991, he was admitted at the age of 60 to hospice after doctors concluded his cancer had spread to the brain. But he survives to this day, though he suffers from garbled speech and for many years needed to be fed through a tube. So, why is he considered terminally ill? That, says Ms. Houillon of UGS, is precisely the issue. While her company's initial analysis centered on how long patients were living, she says, that wasn't the ultimate concern. "Our focus is the medical record itself and the prognosis of the patient," she says. Adds a UGS spokeswoman: "It wasn't a matter of us not being willing to cover these people because they lived too long." Indeed, to investigators checking the medical records, there were numerous indications that Hospice of the North Country was serving some of the wrong patients. The UGS spokeswoman says the hospice 's own physicians didn't come through. The diagnoses need "to be based on the medical . . . criteria, and they didn't meet it," she says. Nurses' notes only deepened the skepticism.

In the case of Mrs. DesParois, the auditor zeroed in on remarks by the nurse that her patient "admits to little pain" and was "not willing to accept death." Mrs. DesParois refused invasive tests to determine whether the cancer had spread to her liver.

The auditor was dubious that she was that sick. Using medical lingo for a patient with metastasizing, or spreading, cancer, the auditor wrote that charts "still show this supposed Liver Mets still living. Did not meet Terminal prognosis." The cost of the treatment was never far from investigators' minds. According to documents, Mrs. Bates suffered from "extensive endometrial cancer . . . obliterating the endocervix and cervical canal." The auditor determined, however, that Mrs. Bates does not show "a major problem" and stated that she "shows no death date to this date." Near the end, the auditor wrote, "Savings: $57,959.59."

Mr. Ouimet's case provided more evidence. "Al is mobile and continues to go out [with] wife for coffee daily -- weather permitting," noted Mrs. Ballard, the hospice nurse. In another note, she wrote that he had "returned from his coffee break" and "is looking well." To the auditor, those remarks buttressed the conclusion that Mr. Ouimet "did not meet terminal illness definition."

To be sure, his long survival had troubled hospice staff even before he came under government scrutiny. Mrs. Ballard says she wondered if "he was staying on too long, but I didn't feel he was costing us that much." Later on, Alfred Hartmann, the co-medical director, reviewed pathology reports to make sure the man really had cancer. (He did.)

The hospice dropped Mr. Ouimet as a patient at the height of the investigation. He is now in a nursing home, where Medicaid picks up the tab, about 15% to 20% higher than hospice care.

The Judge Rules

As the investigation wore on, the hospice decided it needed legal help. It turned to Connie Raffa, a partner at the New York office of Washington law firm Arent Fox. She had spent 15 years working as an attorney at HCFA and had worked on the Puerto Rico fraud cases.

Ms. Raffa could spew out the most obscure details related to hospice regulations. She also knew when to negotiate and when to fight. So when UGS denied the hospice 's request for reconsideration and also declined to meet face to face, she filed for an administrative court hearing. There was a lull, and then in May 1998, UGS moved to begin seizing the hospice 's entire Medicare payments -- averaging $50,000 to $60,000 a month.

UGS was aware such a move could force the hospice into bankruptcy, and the company says it was sympathetic. "We were able to get it down to where they would be paying $12,500 rather than paying the entire amount," says John Gall, reimbursement manager of UGS.

Ms. Raffa decided she needed an intellectual gun of her own. She turned to Nicholas Christakis, an associate professor of medicine and sociology at the University of Chicago. His passion is studying terminal patients who fall outside the bell curve of life expectancy.

Dr. Christakis agreed to advise the hospice at no pay. His conclusion: The patients' longevity was likely a matter of "dumb luck. . . . Fraud wasn't going on here." The hospice had simply ended up with a few "outliers," the term the industry uses to refer to people who beat the odds and survive. "Why should a provider be punished or even reviewed for providing health care that is life prolonging?" he says. Because of the six-month criterion, he adds, hospice is the only realm of health care where providers are measured on the basis of "negative outcomes" -- that is, the more quickly the patients die, the better the hospice fares in the government's eyes. He also notes that in his own study of nearly 200,000 hospice patients, 7.2% of them lived longer than a year, and at least 4% lived longer than two years.

As Ms. Raffa prepared for the hearing, the hospice 's medical directors did considerable soul-searching. Anthony Vaccaro reread the chart of Mrs. Bates, the uterine-cancer patient. "This lady was one of these oddities, she was one of the rare cases, but how are we supposed to know that?" he says. "Our government comes and says you did wrong, but hospice did a wonderful job, and God played a role, and she had a wonderful quality of life." The hearing was held in September 1998. Ms. Raffa argued that Medicare's "zero tolerance" policy required patients "to die on time." The hospice 's own study showed that of 660 patients admitted over a five-year period, 4.8% lived between seven months and a year, and an additional 3.6% lived more than a year.

Administrative Law Judge John Stewart came away unconvinced by the government's case. There was good reason to believe that these patients were terminal when they were admitted, he said. He declared that Medicare's six-month policy was "never intended as a hard and fast rule," and noted that it makes room for the "normal course" of an illness.

The fact that some patients "exceeded those expectations does not indicate that a fraud was perpetrated," he wrote. Rather, he said, "it suggests that health and illness, life and death, are subject to factors and influences beyond the science of medicine."

The judge noted that relatively few patients at the Hospice of the North Country lived beyond six months. That some did, he said, "represents an achievement; it is not indicia of fraud."

The government appealed and lost. Finally, in March 1999, UGS gave the hospice back the roughly $85,000 it had been reimbursed. The hospice is still out $80,000 in legal fees.

The Fiddle Lady

The hospice won its case but now goes about its business very differently. Weekly staff meetings are tense affairs, with staff expected to account for why each patient belongs in hospice. When patients seem to be doing well, there is considerable pressure to discharge them.

Mary Lou Kingsley, a nurse, tells the story of a man known as Jay-Ray. He had heart and lung disease and had been with the hospice for nine months. In May 1998, "we thought we better not keep anybody if they are doing better." And so the hospice discharged him. "A week or two after we discharged him, they found him dead in bed," Ms. Kingsley says. "The question is, did we abandon him and then he died?" Anxiety over the rules has taken a toll. "It really inhibits what you are doing," says Traci Esposito, a nurse. When new patients arrive, "I find myself thinking, `Are they really appropriate? Are they really going to be gone in six months?'"

Admissions are tougher, says Dr. Vaccaro. A few years ago, a doctor "would call and say, `We have a patient with cancer, can you take them?' The answer would be `Sure.' Now it is, `What's the cancer's growth? Will it spread? Will it become symptomatic?'" He is more concerned about taking patients with cardiac or neuromuscular diseases. Multiple-sclerosis patients sometimes "get worse and then get better," he says, while heart patients can appear stable one day and die the next. The hospice has become far more careful with patients' files and is teaching staffers to write charts in "notes worthy of Ernest Hemingway," says Dr. Hartmann, the co-medical director.

A staffer from the Hospice of the Florida Suncoast, a 1,200-patient-a-day operation in St. Petersburg, came to Plattsburgh to show some semantic tricks she had learned to keep out of trouble. She brought a list of do's and don'ts. One suggestion: "Don't use phrases such as, `The patient is stable,' or `patient is unchanged.'" Instead, say something like, "The patient is experiencing improved quality of life with hospice pain and symptom control and supportive services. . . . He is able to eat small amounts of the foods he enjoys at meals with his family without vomiting." Another guideline: Don't say "no signs and symptoms of cardiac disease." Rather, the hospice advises, write that "cardiac symptoms are currently managed due to pain medication regime, assistance of HHA [home health aides] for personal care. . . . Anxiety managed by frequent visits by chaplain and psychosocial professional."

Mary Labyak, president of the Florida hospice, defends these tips as the only way for hospices to survive. Her goal is to "meet the needs of the government without it eating up so much of our time and energy and compassion." The government says its policies have been effective, and that hospice fraud is on the decline. Between 1994 and 1998, average lengths of stay at hospices dropped about 20% to 48 days. At the Hospice of the North Country, the median length of stay has fallen to 17 days this year from 24 days a year ago.

Dr. Berenson, from HCFA, says he realizes that moving people out of hospice care can increase government's costs if those patients wind up in nursing homes or hospitals. That "is a major question," he says. But changing the six-month rule would require congressional action. "Generally, there are any number of statutory requirements that I scratch my head about, but our first obligation is to enforce the statute." The six-month rule "doesn't fit" any longer, says Amber Jones, head of the New York Hospice Association. It came about when nearly all hospice patients had cancer, which is no longer true. The industry is split on whether to lengthen the time period to a year or vary it for different diseases, she says. Dr. Berenson adds that hospices' concerns over patients' charts "are exaggerated. There were some problems identified . . . in the early 1990s which perhaps led to a somewhat aggressive oversight," he says. But "we are finding the balance." He hopes reviewers "are not only looking for key words, but looking for content. It is not appropriate to look for the word `stable' and go, `Ah-hah.'"

So given that, how should Hospice of the North Country make note of the recent, remarkable event in the life of Rose Rushford, 76? Mrs. Rushford, a widow and housewife, has been diagnosed as terminally ill from heart disease. Since May 1999, she has been in hospice care, and Medicare is footing the bill. For many months, she was too ill and too distraught to pursue her lifelong passion, fiddle playing. But, she says, social worker Donna Brockway and others from the hospice "got me out of my shell. I was very depressed, and then my life changed." A few weeks ago, she started knocking out tunes like "Chinese Breakdown" and "Fiddling Fingers." The hospice staff is exultant -- and anxious. "Starting to play means so much to her," explains Ms. Brockway. But she wondered if it should be mentioned on the charts. "If we put it down, it can hurt us." Ms. Anderson, the hospice director, recently decided they had better come out and use the word "fiddle."

If Mrs. Rushford makes much more progress, the hospice may need to discharge her. "We would obey the law, but we wouldn't be happy about it," says Ms. Anderson. "We would be darn unhappy."

None of which makes much sense to old-timers like Mrs. Ballard. "Once you take on an obligation, you have an obligation," she says. "You don't say, `Well, you are living too long. Goodbye.'"

Copyright © 2000 Dow Jones & Company, Inc. All Rights Reserved. Used with permission.

Article #2

Medicare Head Tackles Criticism On Hospice Care

By Lucette Lagnado

09/15/2000

The Wall Street Journal

Page B 1

(Copyright © 2000, Dow Jones & Company, Inc., used with permission)

Uncle Sam has some reassuring news for terminally ill patients: It's OK to live beyond the six-month deadline dictated by federal guidelines for reimbursement of hospice care.

In a strongly worded letter being sent to 2,200 hospices this week, the outgoing head of the Health Care Financing Administration, which runs Medicare, says she wants to counter a "disturbing misperception" among those who care for the dying that patients who outlive the narrow reimbursement timeline set by Congress risk losing their coverage and being hit with severe financial penalties. "Nothing can be further from the truth," HCFA administrator Nancy-Ann Min DeParle writes in the letter, dated Tuesday and also being sent to Medicare contractors. "Let me be clear: In no way are hospice beneficiaries restricted to six months of coverage."

Medicare law allows the terminally ill to obtain special care from hospice providers, including nursing care, psychological support, medication, even spiritual counseling, often in their own home. But to qualify, doctors have to certify that the patient will likely die within six months. While the law provides for extensions, hospice providers complain they have come under pressure to accept only patients who are at death's door and to turn away those with diseases such as Alzheimer's who may linger beyond the half-year cutoff. In some cases, hospices with patients who live longer have faced stiff bills from Medicare asking for repayment.

The original law is both rigid and open to interpretation; it states that to qualify for hospice care, "the individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course." Hospice -industry activists say the government in recent years has seemed to stress only the six-month part of the law. As the issue of compassionate care for the dying becomes a hot topic of debate, the Medicare chief is trying to emphasize that there is indeed no real deadline to die.

Medicare officials say they hope Ms. DeParle's letter will address some issues that have arisen in past months, including a front-page story in The Wall Street Journal about a small hospice in Plattsburgh, N.Y., which was hit with a large Medicare bill because some of its patients had lived far beyond six months. Back in June, the Journal recounted the travails of the Hospice of the North Country, where a group of elderly patients, mostly in their 80's and 90's, were accused of cheating Medicare because they beat the odds and lived years after their terminal diagnoses.

The Plattsburgh hospice was asked to repay Medicare nearly $450,000, a sum that would have forced it to close. Instead, it fought back, hiring a New York lawyer, who appealed the Medicare ruling before a federal administrative law judge. The hospice prevailed: In late 1998, the judge not only ruled on the side of the little Hospice of the North Country but chided the government, saying the fact that some patients lived beyond six months "represents an achievement; it is not an indicia of fraud."

Still, the Plattsburgh experience and others like it have left the industry shaken. A number of hospices have said they have been subjected to rigorous audits by Medicare contractors. Bitterness and suspicion have marked the relationship between the industry, Medicare and its contractors.

Congress established the hospice benefit under Medicare back in the 1980s. The program grew; HCFA says that between fiscal 1998 and fiscal 1999 alone, expenditures rose to nearly $2.5 billion from $2.17 billion. But incidents of abuse prompted a crackdown by the Inspector General of the Department of Health and Human Services, which oversees HCFA and Medicare. Ms. DeParle acknowledges that there is a problem. "I am concerned that some individuals who want and could benefit from hospice care may not be receiving it, or may be receiving it late in the course of their illness," she says in her letter.

Ms. DeParle proposes in her letter a pilot program in which hospices could obtain preauthorization from Medicare contractors for hospice care "in cases where the prognosis is difficult." Such a program would preempt "concerns about denial of claims" and therefore encourage "earlier enrollment for more beneficiaries," she writes.

Ms. DeParle's letter also comes ahead of a Monday hearing before the Senate Special Committee on Aging, which is expected to scrutinize the six-month rule and explore whether terminally ill patients may have been unfairly denied access to hospice care.

Kathleen Foley, a pain specialist at the Memorial Sloan-Kettering Cancer Center in New York, wondered whether Ms. DeParle's letter is "rhetoric or reform." Dr. Foley says that many patients with Alzheimer's or multiple sclerosis are seeking hospice care, but that it is difficult to offer an exact prognosis of when they will die. Many cancer and AIDS patients are also living longer than expected because of new treatments. "We need eligibility criteria that aren't time-dependent," she says.

Questions for Ms. DeParle were referred to Robert Berenson, who oversees the hospice benefit at HCFA. "We don't see a need for a fundamental legislative change," he says. But he adds that the proposed pre-authorization program "should provide some comfort."

Amber Jones, who heads the New York State Hospice Association, says the HCFA letter is "awesome," but she questions the proposal to have precertification. Decisions on whom to admit and whom to keep, she says, should be left in the hands of the hospice physician instead of granting more power over care for the dying to government contractors and bureaucrats.

Copyright © 2000 Dow Jones & Company, Inc. All Rights Reserved. Used with permission.

Article #3

Senate Committee Chairman Will Ask Medicare to Review Hospice-Care Benefit

By Lucette Lagnado

09/19/2000

The Wall Street Journal

Page B 23

(Copyright © 2000, Dow Jones & Company, Inc., used with permission)

The chairman of the Senate Special Committee on Aging said he will ask Medicare to examine whether the six-month eligibility rule for hospice care for the dying still makes sense, in light of evidence that the rule has become an "arbitrary" club impeding access to end-of-life care.

After a hearing at the Capitol in Washington, where a number of witnesses challenged the six-month criteria for hospice care, Sen. Charles Grassley, (R., Iowa) said he had come away wondering, "Should we have a different approach?" for implementing the Medicare hospice benefit.

"There is plenty of confusion," under the current system, Sen. Grassley said in an interview. Witnesses at the hearing included hospice -industry experts, as well as the author of the original law establishing hospice care under Medicare, former Senate Majority Leader Robert Dole. Mr. Dole told the committee he had never intended the six-month rule to be used as a "barrier" to keep dying Americans from accessing care. Under Medicare, hospice offers a full range of services to a terminally ill patient, including nursing care and pastoral guidance, often at a dying patient's home. But in order for a patient to qualify for the benefit, a doctor must certify that the patient will likely die within six months.

Though extensions are available, hospice providers have complained that the law is being interpreted so rigidly that it has created a "deadline" for people to expire. In a page-one story in June, The Wall Street Journal profiled a small upstate New York hospice that had been financially penalized by Medicare for providing care to dying patients who survived beyond six-month limit.

"My feeling is even though the six-month rule was not intended to be arbitrary it has turned out to be arbitrary," said Sen. Grassley. He added that "the law may be too strict." He said he is asking Medicare to review the benefit. He has, in fact, given Medicare a six-month deadline to perform the analysis. A spokesman for the Health Care Financing Administration, which administers Medicare, said the agency will seriously consider the senator's request when it receives his letter. In his closing remarks, Sen. Grassley said he was asking Medicare to examine whether the benefit should move away from a time limit to one that would consider a patient's disease trajectory. Some terminally ill patients with Alzheimer's, AIDS or MS may take longer than six months to die, prompting some to urge that the government examine other factors, such as how long someone is bedridden, to decide if they qualify for hospice .

Last week, Nancy-Ann Min DeParle, who runs the HCFA, sent a letter to the hospice providers saying there was a "disturbing misperception" that hospices and their patients would be punished if they, in effect, lived too long.

Copyright © 2000 Dow Jones & Company, Inc. All Rights Reserved. Used with permission.