State legislators, in an attempt to balance the budget, have cut care options for some terminally ill Arizonans, and hospices may have to repay the state for services already provided.
A footnote in the Legislature's 2007 General Appropriation Act allowed the Arizona Health Care Cost Containment System to match federal funds for hospice services needed by acute-care patients. It was a one-year appropriation that was renewed in 2008, but not for the fiscal year that began on July 1, 2009. Even though legislators approved the budget in July, AHCCCS continued authorizing hospice payments for another six months.
Last month, AHCCCS sent a letter to providers telling them that the funding had been eliminated, and it suggested they would have to repay the state.
Because of the state's budget crisis, the end of the legislative session was "a confusing time," said Monica Coury, a spokeswoman for AHCCCS. "Normally we might have been able to provide notification sooner. We didn't provide it as soon as we would have liked to."
AHCCCS members enrolled in the agency's long-term-care program retain their hospice benefits, but other patients likely will end up in hospital emergency rooms without the hospice benefit. The average hospice stay is 20 days, according to the National Hospice and Palliative Care Organization.
"Typically in the hospice world, individuals are not seeking aggressive treatment anymore; they are seeking comfort care," said Agnes Poore, chief clinical officer and co-founder of Casa de la Luz Hospice. "But typically in the hospital, they might do diagnostic tests. If you need pain management, they might admit you to the hospital. Emergency room and hospital costs are enormous compared to what you would pay for hospice care."
Last year, 541 acute-care hospice patients were enrolled in AHCCCS. Those same patients would not be eligible for AHCCCS-funded hospice benefits today.
Hospice providers in Tucson estimate the average cost for a day of hospice care - which includes medication, equipment, staffing, and spiritual and social support in a patient's home - is $140. The alternative now for low-income patients who lost their AHCCCS hospice benefits is hospitalization, which can cost up to 10 times more.
"Under hospice . . . they aren't ordering expensive tests and treatments," said Marie Fredette, executive director of the Tempe-based Arizona Hospice & Palliative Care Organization. "If you show up in an emergency room and you're in pain, a doctor is going to order tests and treatments."
"They still qualify for AHCCCS to go to the hospital, and the hospital will bill AHCCCS at a significantly higher rate than they would be billed by hospice. The hospitals have to take these patients if they show up in the emergency room. If the hospice benefit was still in place, they could elect to go into hospice.
"It's a knee-jerk reaction to saving money in the short term," Fredette said. "In the long term, it's going to cost millions."
Bonnie Knobloch, executive director of Carondelet Hospice & Palliative Care, agreed.
"Plus, it's the right thing to do for the patients and families," she said, referring to offering hospice care to all who need it.
Arizona hospice providers now are faced with difficult decisions: Can they afford to provide free care for current and future patients who no longer are funded by AHCCCS? If not, where do they send them? And how can they afford to repay the state fees already earned for providing care?
"There are multiple levels of impact to this decision," Knobloch said. "The most profoundly upsetting thing is they want to . . . take back money they've given to us since July, which is unheard of. In this day and age, it is a travesty, because we are denying care to the people who most need it at their most vulnerable time - at the end of their life. It is diminishing the quality of life for those who are struggling to cope with pain management and all those things that go along with dying."
Most hospice patients - 75 percent to 80 percent - are covered by Medicare, while the rest have insurance or AHCCCS benefits, Knobloch said.
Carondelet will continue caring for acute AHCCCS patients already receiving its services, and for now the company has no plans to turn away future patients for financial reasons. However, "certainly over time we will have to investigate the impact of this on our organization."
If AHCCCS pursues repayment, it could cost small hospices thousands of dollars and larger hospices millions. The management at one small Arizona hospice told Fredette that it will have to repay $77,000 for pre-authorized services provided to acute-care AHCCCS patients since last July.
"This will put providers out of business," Fredette said. "Small providers, there's no way they can pay that money back. Even if they don't have to pay the money back, these patients have nowhere to go."
Contact reporter Kimberly Matas at firstname.lastname@example.org or at 573-4191.