Learning the Right Lessons from Hospice

Health policymakers love the idea of hospice. Yet Medicare seems to be learning exactly the wrong lessons from the success of the program, which provides well-integrated patient-centered comfort care to people with terminal illness. Instead of trying to understand why hospice is growing in popularity, Medicare is instead making it harder to enroll.

As often happens in its regulation of health care, Medicare is focusing on abuses. And make no mistake, those concerns are real when it comes to the $14 billion hospice business. Providers have figured out clever ways to game Medicare, which pays for 84 percent of all hospice care. One big one: enrolling patients who are not terminally ill, or at least not likely to die within the six-month window Medicare requires. A nice Kaiser Health News article by Randy Dotinga describes what happened to San Diego Hospice when Medicare auditors cracked down on its enrollment practices. 

But by focusing on fraud, Medicare is missing the bigger point. Hospices are doing something right and they are doing it in a way that patients and their families really like. Instead of trying to make coordinated, comfort-based care fit into the limits of the hospice box,  policymakers should be figuring out how to take what hospice does well and expand it through the rest of the health system.

As Melissa Aldridge Carlson and her coauthors put it in a December  Health Affairs article, “Hospice is a model of health care consistent with the country’s stated health care reform goals: It is patient centered; it uses a multidisciplinary care team; it is coordinated across settings; it reduces unnecessary hospitalizations; and it saves health care dollars.”

Demand for hospice is booming. We know this because both enrollment and the number of hospices are growing.  In 2011, 1.65 million people received hospice care, up 16 percent from 2007, according to the National Hospice and Palliative Care Organization. Nearly 45 percent of all people who died in the U.S. had  hospice care (though many for only a few days). From 2007 to 2011, the number of hospices grew from 4500 to 5300, and all that expansion was from for-profit firms.  

There is no doubt that some of the popularity of hospice is itself a result of the growth of the providers. Health care is often driven by supply: A new cardiac center opens and suddenly more people need stents. A new hospice opens and, thanks to aggressive marketing, more people get comfort care.

Yet, the market is telling us that hospice is offering a service people want. Remember, patients are usually required to give up standard treatment for their terminal disease in order to enroll. And they can easily drop hospice care and return to curative treatment whenever they want. But relatively few do.  

Hospice is designed for people with terminal illnesses.  Medicare requires that a physician certify that a person is likely to die within six months before she can be enrolled. And while hospice once was almost exclusively for cancer patients (where such a prognosis could be relatively accurate), increasingly patients have illnesses such as heart disease and dementia where it is much harder to project lifespan.

Perhaps many of these patients are not yet hospice appropriate, and, as Medicare claims, are enrolled too soon. But they are still candidates for team-based, patient-centered, integrated care that provides comfort, reduces pain, and provides for their social and spiritual needs.  

Already, non-hospice palliative care programs do some of this. But there is plenty of room for more. The real lesson: You should not have to be dying to get this care. It would be nice if policymakers put as much energy into designing care systems to make that happen as into cracking down on hospice fraud.

Full disclosure: My wife is a chaplain at a non-profit hospice.   

 

Comments

  1. Mary Jean Holt says:

    This article is excellent & makes some very good points, which I totlly agree with!

  2. Barbara Chandler says:

    I recently completed training to become a hospice volunteer. I was very impressed with the level of care provided and kept thinking how sad it was that residents of nursing homes are only eligible to receive this level of care in the last six months of their lives. Many of these residents live for years in nursing homes and they shouldn’t have to wait until they are dying to receive a level of care that should be the standard of care for all nursing homes residents.

  3. Terry Cahill says:

    I have been a hospice medical director for 20 years in a small rural community. Large systems are withdrawing hospice services and using”palliative care” as the label for aggressive care that is reimbursed the same as other medical care (including TPN)and then send patients to us who die within 72 hours with no chance to provide the true value of hospice care to the patients and their families.

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