Reconsider "Unrelated" Drugs As You Use CMS' New Hospice Election Addendum

Get your copy of CMS' newly posted Hospice Election Addendum here. When CMS posted its newest version of the Hospice Election Statement a few days ago, the updated Election Addendum was promised soon. Of course, its real name is the Model Example of “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”, but that name is just too long to write every time. Right? It does, however, remind us of the purpose of the addendum. As long as you use it according to current parameters, this form won't get you into trouble, for now. 

But beware that CMS continues to capture data about Medicare spending outside of the hospice benefit for beneficiaries who have elected to receive care under the hospice benefit. Make sure you understand the related vs. unrelated items, services, drugs and conditions. CMS has not rescinded the requirement that the hospice physician document clear clinical evidence of why such elements are unrelated to the patient's terminal prognosis and symptom burden. 

For example, be sure that if you're not paying for a patient's insulin or oral antidiabetic medication, you are not also using diabetes mellitus as a comorbid condition that contributes to the patient's poor prognosis. Keep in mind what Medicare continues to say about anything unrelated to a beneficiary's hospice-related needs:

We believe that it would be unusual and exceptional to see services provided outside of hospice for those individuals who are approaching the end of life and we have reiterated since 1983 that “virtually all” care needed by the terminally ill individual would be provided by the hospice." (FY 2024 Hospice Final Rule)

If your agency routinely considers insulin, B-12 injections, thyroid medication, beta blockers, and other maintenance drugs to be unrelated to every hospice terminal prognosis, consider potential consequences of continuing a practice that ignores Medicare's warning that unrelated medications are rare. And when something is truly unrelated, be sure you have physician's documentation of clear clinical evidence of why withdrawing that medication would not contribute to that patient's symptom burden.

CMS also says in the FY 2024 Final Rule: 

"After a hospice election, many maintenance drugs or drugs used to treat or cure a condition are typically discontinued as the focus of care shifts to palliation and comfort measures. However, those same drugs may be appropriate to continue as they may offer symptom relief for the palliation and management of the terminal prognosis."

Perhaps the interdisciplinary team, including the physician, should consider whether withdrawing the medication would contribute to the patient's discomfort before determining that it is unrelated to the patient's terminal prognosis.