With every passing day, we hear of more ways that HMOs,
managed care organizations and other health insurers are acting
to cut their costs by cutting services or supplies provided to
the patients they are supposed to serve. Hospice patients and
their families must also be vigilant to make sure that they
receive the medications which their physician has ordered ... not
just a substitute that the HMO, managed care organization or even
the hospice substitutes to save them money, possible placing you
or your loved one at risk.
There may be several types of medications available to treat any
particular disease or condition. Your physician is the
professional most knowledgeable about which medication is best
for you or your loved one. When the physician chooses to order a
medication, it is because he or she knows your particular
condition, history and how you have responded to medications in
the past. For example, one medication may control high blood
pressure very well, while another similar medication may
completely fail to do the job. Substituting the cheaper
medication may make dollar sense to the health insurance company
or hospice, but it could be deadly for you or your loved one, ...
and the physician is the only one with the authority to prescribe
medications: not the HMO, not the managed care organization, and
not the hospice!
How this applies to Hospice Patients
When your physician wrote prescriptions for health conditions
or diseases which your loved one has, it was mostly likely done
with careful consideration of many factors specific to the case.
A patient that enters hospice for a terminal illness may have
other conditions or diseases besides the "terminal
illness." For example, a patient with congestive heart
failure may also develop a terminal cancer. Hospices are
responsible to pay for the medications related to the terminal
illness out of whatever reimbursement they get for their services
(minus up to a 5% copay/maximum of $5.- per prescription). The
hospice is not responsible to pay for medications which are not
related to the terminal illness.
In the example above, the physician who ordered medications for
a patient with congestive heart failure knows the patient's
condition and history. Just because a terminal cancer has been
diagnosed, does not mean that the medication for the heart
condition should be stopped. Stopping all other medications (for
non-terminal conditions) can hasten death and cause severe
problems and symptoms.
Hospice is not about hastening death, but about providing proper
comfort care. Medications for non-terminal diseases are normally
continued all the way up until the end, when the patient is so
close to death that taking those medications is more of a problem
than a help.
Hospices may sometimes choose to try to change a patient's
medications. This could be done for several reasons. Sometimes,
it is simply because the patient is close to death and does not
need those medications. But even if the patient is not close to
death, some hospices still choose to try to have the medications
changed. You do not have to accept those changes. The hospice
does not pay for those medications, and you can choose to have
those continued. Even if you are enrolled in hospice, if you have
private insurance, you likely still have coverage for
non-terminal illnesses through that health insurance. If the
hospice suddenly "pulls" all your medications related
to non-terminal illnesses, call your physician and ask him
directly if that is his wish and doctor's order. You do not
have to allow all medications to be pulled. You do not have to
allow medications to be switched against your will.
In many cases, your physician may not be aware of all the
changes the hospice is making or may not be fully aware of your
actual condition. In some cases, the hospice may claim that your
loved one is "declining" and doesn't need these
medications any more. If that is the case, and your loved one is
actually very close to death, it may be appropriate to withdraw
all medications, except those which provide comfort and manage
symptoms for your loved one. But again, that is for your
physician to decide, not a hospice agency, nurse or pharmacy.
What About if the Medication Being Switched
is for the Terminal Illness?
If your physician has ordered specific medications to control
symptoms related to your loved one's terminal illness, and
the hospice all of a sudden wishes to substitute other
medications, you need to ask questions. Is the new medication
more effective than the one your attending physician originally
ordered? Is the new medication cheaper and is that the reason
it's being changed? If the new substitute medication is
effective, then there is no problem. If however, the new
substitute medication does not provide the results desired and
your loved one's symptoms are not properly controlled (or
worse), then you need to let your physician know about that. You
will need to discuss these questions with the hospice RN case
manager. If you don't get a prompt reply that satisfies you,
then call your attending physician.
What to Do If the Hospice Refuses
to Switch Back To the Better Medication
Hospices may be within their rights to substitute equally
effective medications for a prescription originally ordered by
your physician. However, your physician must approve the switch,
because no medication may be dispensed without a physician's
order. If the hospice refuses to provide medications which
actually do provide effective symptom management and relief, then
the hospice would be in violation of a basic condition of hospice
care: the hospice must make sure that their patients'
symptoms are managed as well as possible and that your loved one
is kept as comfortable as possible. This means that, according to
the regulations, all medications necessary to meet the needs of
your loved one must be provided.
When the result of a medication switch is uncontrolled symptoms,
then the hospice is out of compliance with the standards. You can
discuss this with the RN case manager and the hospice director.
If no prompt changes are made, the hospice medical director is
obligated to act on your behalf. If not, you can file a complaint
with the State and other regulatory agencies and provide the
hospice with a copy. You can switch hospices, or you can choose
to pay for the medication yourself and work out reimbursement
from the hospice later (that would be the last option
Physicians may be Rewarded For Doing Less
Sad to say, but in some cases, the physician may be ordering
medications according to direction from the health insurance plan
and not according to what is best for your loved one. Physicians
are rewarded with substantial financial bonuses when they cut HMO
or health insurance plan costs. The reward can amount to tens of
thousands of dollars or more.
Consider the following actual case of two physicians in the same
group practice, both who saw an equal number of patients last
year. One physician complied with all HMO requests, cut costs and
ordered only the medications and lab tests approved by the HMO.
The other physician ordered only the medications which she
believed to be the best for the patient and insisted on ordering
all tests needed to provide proper medical care for her patients.
She fought the HMO, argued on behalf of her patients and saved
many of their lives by doing what was right.
Who got the most money at the end of the year? The doctor who
complied with the HMO wishes and provided the least care! He
earned $140,000 last year. The doctor who did everything for her
patients and saw an equal number of patients as the other doctor
got $65,000. And the physician who received the $65,000 by doing
the right thing for her patients is now considering leaving the
medical profession! HMOs and managed care are destroying the
medical profession by rewarding physicians who do not provide the
best services for their patients and by punishing those
physicians who do provide the best services for their patients.
So in some cases, it is no longer safe to assume that even your
physician will always be doing what is best for your loved one.
You've got to become knowledgeable about your loved one's
condition, needs and why each medication is given. We have
received complaints about some hospices requiring their patients
to switch physicians when they enrolled in hospice; the hospice
had all patients signed up to use the services of the hospice
physician. This is completely inappropriate. In no case
should you have to switch from your attending physician to the
Hospice's own medical doctor just because you enroll in
hospice. This is not a requirement of hospice. You have
a right to keep your own physician when you enroll in hospice.
Substitutions for Medications
Occur In many Health Care Situations
Substitutions of medications ordered by your physician may
occur in many areas of health care: hospitals, nursing homes, HMO
health centers, pharmacy, home care and hospice. You need to be
vigilant and if necessary, assertive to make sure you or your
loved one get the medication that is needed for the illness being
treated. For example, some patients have been denied specific
forms of medications for asthma or diabetes and had their lives
endangered when substitutions of medications were made against
their physician's original orders. Being aware of the problem
and asking pertinent questions can protect your loved ones. In
hospice care, being vigilant and asking questions can help your
loved one have a death with dignity and reduce unnecessary