In what amounts to a victory for hospice patients and their families nationwide, Centers for Medicare and Medicaid Services (CMS) officials last week revoked the prior authorization process for many drugs used in hospice care. Back in March CMS finalized rules that required patients and families to seek out a prior-authorization for ALL medications they take which are 'unrelated to the terminal diagnosis' or the symptoms they experience as a result of that illness. But many patients continue to benefit from treatments for other chronic diseases, even in their last months of life. A good example would be a person with end-stage congestive heart failure AND emphysema. Medications that control the emphysema (like inhalers) would require a prior-authorization. These burdensome requirements have caused problems for many who attempt to access the hospice program.

Under the revised guidance, the only classes of medications that will require a prior-authorization are the classes of medications that hospice should typically be paying for anyhow:

  • anti-anxiety drugs
  • anti-nauseants
  • laxatives
  • pain relievers

According to Kaiser Health News' "Capsules," the four categories were decided upon after an HHS investigation found that Part D plans in 2009 had paid more than $33 million for these types of drugs. But they should have been covered by hospice (Jaffe, "Capsules," Kaiser Health News, 7/18). That leaves the door open to continued Medicare D billing for non-hospice diagnosis medications that are felt to maintain quality of life during the hospice period. Of course, Medicare D plans will need to be notified that a medication is "unrelated."

The ruling strikes a delicate balance between: 

a. ensuring that Medicare D is generally not paying for the most common hospice-related medications for the most frequently seen symptoms of any acute or chronic terminal disease (pain, nausea, constipation, anxiety)

b. ensuring that hospice patients continue to receive other medications via Medicare-D if the patient and hospice provider agree it continues to maintain or improve their quality of life

c. ensuring that there are no needless or dangerous delays for extremely ill patients to receive the medications they need.