As Marge Bowen examined her, Bessie Richburg lay in a hospital bed in the sunny second-floor bedroom of her West Philadelphia rowhouse with her eyes closed.
The muscles of her face rippled and twitched as if preparing for words or an awakening that never came. At 88 and somewhere shy of 70 pounds, Richburg looked wizened and gnomelike among the cheery flowered sheets and blankets.
Bowen, a nurse practitioner with the University of Pennsylvania Health System's Wissahickon Hospice, had come to see whether Richburg still qualified for hospice, which is aimed at people who probably will die within six months. Richburg, who has dementia, has been on hospice since December 2009.
New government rules -- enforcement kicked in last month -- require hospices to send doctors or nurse practitioners for face-to-face visits with Medicare patients who have been on hospice more than six months to certify that the patients are really sick enough to need the program. The new rules came in response to lengthening hospice stays as services expanded beyond cancer patients to those with slower-moving and less predictable illnesses like heart failure, Alzheimer's and chronic obstructive pulmonary disease.