Hospice Pharmacy Insights June 2021

It is that time of year again, where the Centers for Medicare and Medicaid (CMS) releases its “proposed rule” for the coming fiscal year and solicits comments from the public and hospices receiving Medicare funds. This year is no different. The specific areas that CMS is focusing on for FY 2022 are the following:

• Utilization of services and levels of care
• Length of hospice stay
• Live discharges
• Service intensity add-ons (SIA)
• Spending outside of the hospice election (especially Medicare Part D).

This month’s newsletter will focus on this last bullet point.

Hospices are responsible for covering drugs and biologicals related to the palliation and management of the terminal illness and related conditions while the patient is under hospice care. For a prescription drug to be covered under Part D for an individual enrolled in hospice, the drug must be for treatment completely unrelated to the terminal illness or related conditions. 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. According to CMS, non-hospice spending for Part D drugs increased from $353 million in FY 2016 to $499 million in FY 2019.

Analysis of Part D prescription drug events (PDEs) data suggests that the current use of prior authorization (PA) by Part D sponsors has reduced Part D program payments for drugs in four targeted categories (analgesics, anti-nauseants, anti-anxiety, and laxatives), which are typically used to treat common symptoms experienced during the end of life. However, under Medicare Part D there has been an increase in hospice beneficiaries filling prescriptions for a separate category of drugs we refer to as maintenance drugs (https://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​Hospice/​Downloads/​2016-11-15-Part-D-Hospice-Guidance.pdf).

Under CMS’s current policy, Part D sponsors are not expected to place hospice PA requirements on categories of drugs (other than the four targeted categories listed above) or take special measures beyond their normal compliance and utilization review activities. Under this policy, sponsors are not expected to place PA requirements on maintenance drugs, for beneficiaries under a hospice election, though these drugs may still be subject to standard Part D formulary management practices. This policy was put in place to recognize the operational challenges associated with requiring PA on all drugs for beneficiaries who have elected hospice and the potential barriers to access that could be created by requiring PA on all drugs. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma, and diabetes. These categories include beta-blockers, calcium channel blockers, corticosteroids, and insulin.

Since 2014 CMS has narrowed what can be considered “unrelated” for patients electing the hospice benefit. It is our opinion that the CMS comments related to “maintenance” drugs are a heads up to hospices that they are planning to further limit what will be considered “…Hospice Non-Covered Items, Services, and Drugs.”