It’s Time to Change the Medicare Hospice Dementia Criteria

It is time for Medicare to change its hospice criteria for people with dementia.  The current criteria isn’t reflective of the progression of many dementia patients with other chronic illnesses.  It can be difficult to get  dementia patients accepted to hospice because either they haven’t lost 10% of their weight or still speak more than five to six words. Meanwhile, they can’t bath,dress, feed themselves, are incontinent and are knocking on heaven’s door.  Families are overwhelmed.

It is a travesty for many families who have been told their loved one is dying and can’t receive hospice benefits.   The hospice experience, is an invaluable service of support and caring during a difficult time.  They offer a new medical team to provide overall care and pain management, more direct nursing care, emotional and spiritual support, volunteers to sit with the patient and support for the family.

I had a client who’s father had dementia and was in a nursing home.  He kept asking for a hospice evaluation. Each time he was refused hospice services because there was not enough weight loss or his father had been chatty that day.    The nursing home doctor (and this isn’t unusual), kept telling my client, his father was doing so well on the medications he prescribed.  When my client reminded him he was dying, the doctor said it was his responsibility to keep him in the best health.  My client was finally able to get hospice in place five days before he died.  This is not an unusual story with dementia patients.

It wasn’t till 1995 that Medicare allowed non cancer diagnosis to have hospice benefits.  Part of the hesitation and strict criteria for dementia is the inability to predict or diagnosis a six month prognosis.  To qualify for hospice benefits, a physician has to provide a diagnosis of six months or less to death.   How can anyone accurately predict death?

Nobody wants to be accused of Medicare fraud or abuse.  This is a major concern because one of the reasons Medicare has such a strict criteria is to curtail any potential fraud and abuse.  It seems, in the past, there have been doctors and hospice companies that have lied about the life expectancy of patients to get the medicare reimbursements.

I believe it is time to  revisit  the hospice criteria for dementia. It no longer adequately addresses the needs of the growing dementia population and their families.