By Rosemary Gibson
As 10,000 baby boomers turn 65 every day, Medicare spending will skyrocket. About 30 percent of Medicare’s costs are for care in the last year of life. Research has shown that many people nearing the end of life are not informed of their treatment options and their doctors are unaware of their preferences for treatment, which contributes to a lower quality of life at the end of life.
Every family is touched by the end of life of a loved one. Every reporter who covers Medicare policy and health and aging issues will want to know about hospice and palliative care.
Hospice care: What it is
Hospice is for people for whom a cure is no longer possible. They have to meet Medicare eligibility requirements.
- Two doctors – including the hospice medical director – have to certify that the person is terminally ill and is expected to live 6 months or less if their disease runs its normal course
- The person must agree to forgo Medicare coverage for curative treatment for their terminal illness. At any time, the patient can disenroll from hospice and go back to receiving full Medicare benefits
- Care provided includes relief of pain, shortness of breath and other symptoms
- Hospices provide services that are not usually covered by traditional Medicare such as social work services, pastoral care, and bereavement counseling for family members after their loved one dies
- Hospice care is provided in the home, a hospice facility, a hospital or nursing home.
Congress included hospice as a Medicare benefit in 1982. Hospices are paid a per diem for every day a person receives care. Private insurance usually covers hospice care.
Hospice: A growth industry
Hospice is enrolling more people and Medicare spending is increasing. According to the Medicare Payment Advisory Commission, in 2009:
- 1.1 million people received hospice services
- Medicare spent $12 billion on hospice services
- 3,500 hospice providers received Medicare reimbursement, a 50 percent increase from 2000; most of the growth has been among for-profit hospice providers
Palliative care: How it differs from hospice
Palliative care is a relatively new addition to the continuum of medical care. It began to grow in the mid-1990s when physician-assisted suicide became a hotly debated subject. Mike Wallace interviewed Dr. Jack Kevorkian on 60 Minutes in 1998. The program aired a videotape that Kevorkian had recorded two months earlier that showed him giving a lethal injection to a man with Lou Gehrig’s disease.
The 60 Minutes segment was a wake-up call for the medical profession. There was a void in the care of people who had acute or chronic illnesses and were not imminently dying. They had unmet physical, emotional, and spiritual needs. Palliative care was seen as filling the void so that seriously ill people would not have to resort to ending their lives.
The number of doctors providing palliative care started to increase. Palliative medicine was recognized as a new specialty in 2006 by the American Board of Medical Specialties, which acknowledged an unprecedented consensus in the medical profession on the importance of this new specialty
The American Academy of Hospice and Palliative Medicine maintains a national directory of physicians who are board certified in palliative medicine.
Palliative care differs from hospice in the following ways:
- It is for people who are at any stage of illness whether it is curable, chronic, or life-threatening
- There are no formal eligibility requirements as there are for hospice care
- People who receive palliative care don’t have to give up curative treatment
- Palliative care can be provided along with life-prolonging surgery or chemotherapy
- It is provided to people with a range of conditions including cancer, kidney disease, heart failure, HIV/AIDs and Lou Gehrig’s disease
- Palliative care is provided in hospitals, nursing homes, at home and in assisted living facilities.
- It can relieve pain, shortness of breath, and other distressing symptoms, and help people make informed decisions about their treatment options
Hospital-based palliative care
In the early 1990s, only a very small number of hospitals had palliative care teams. This changed as more doctors and nurses entered the field and began to provide palliative care to patients. Some hospitals have a team of physicians, nurses, social workers and clergy. Other hospitals may have only a designated palliative care physician or nurse. The Center to Advance Palliative Care at the Mount Sinai School of Medicine has a training program to help doctors and nurses establish palliative care programs in their hospitals.
Today, about 63 percent of hospitals have a palliative care program. This report card grades the states based on how many hospitals have palliative care services.
The lack of doctors trained in palliative medicine is a barrier to expanding access. Harvard Medical School reports a workforce shortage of 5,000 – 11,000 palliative care physicians.
Hospice and palliative care both rely on nurses. The first hospice – the Connecticut Hospice in Branford, Conn. – was established by Florence Wald, a former dean of Yale University Nursing School. The number of nurses certified in hospice and palliative care has increased but there are not enough nurses to meet the need. (See Hospice and Palliative Care Nurses Association.)
Cutting-edge research
Doctors at Massachusetts General Hospital are studying the impact of palliative care on how long people live. A 2010 study published in the New England Journal of Medicine found that people with metastatic lung cancer who received palliative care early in their diagnosis and had less aggressive end-of-life care lived 2.7 months longer than those who received standard treatment. The patients reported feeling better and had a higher quality of life. Expect more research on the impact of palliative care on how long people live.
New developments/trends for reporters to watch
Hospice care has been in the news recently as the Office of the Inspector General in the U.S. Department of Health and Human Services and the U.S. Department of Justice crack down on hospices that aren’t following Medicare rules.
Bloomberg News published an investigation of hospices that enrolled people who were not terminally ill, a violation of Medicare eligibility requirements. It reveals the role of private equity firms in the hospice industry.
Whistleblowers are alleging fraud committed by their former hospice employers. Kaiser Health News reported on a whistleblower complaint that was joined by the federal government against a for-profit hospice that allegedly submitted false Medicare claims for non-terminally ill people. The whistleblowers allege their employer offered incentives to employees (massage chairs, trips to exotic locations, etc.) to encourage them to meet aggressive enrollment targets. See the U.S. Department of Justice press release.
These reports are in addition to earlier actions by the Justice Department against hospices for abusing the benefit.
What’s ahead?
As Medicare spending continues to increase, the cost of care at the end of life – and the quality of that care – will be an ongoing challenge. The hospice industry will continue to grow. How Congress slows the unsustainable growth in Medicare spending – and its impact on end-of-life care – will surely be a hot topic.
Sources
National Hospital and Palliative Care Organization
Contact: Don Schumacher, President and CEO
Phone: 703-837-3136
Email: dschumacher@nhpco.org
Center to Advance Palliative Care
Contact: Lisa Morgan, Communications/Media Outreach
Phone: 202-201-2675
Email: lisa.morgan@mssm.edu
National Palliative Care Research Center
Contact: Dr. Sean Morrison, Director
Phone: 212-241-6796
Email: sean.morrison@mssm.edu
Hospice and palliative care nursing
Contact: Dr. Betty Ferrell, City of Hope
Email: bferrell@smtplink.coh.org
Hospice and palliative care in nursing homes
Contact: Dr. Joan Teno, Brown University
Email: joan_teno@brown.edu
Websites
- Medicare website with information on the hospice benefit
- National Hospice and Palliative Care Organization
- Center to Advance Palliative Care
- List of hospitals with palliative care programs by state
- National Palliative Care Report Card – America’s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals
- For the number and distribution of hospitals with palliative care according to congressional district
- National Palliative Care Research Center
- Hospice News Network provides updates on hospice topics and is published by a consortium of state hospice organizations. It’s available by subscription. It can be found using online search engines.
Rosemary Gibson is the author of “Wall of Silence,” “The Treatment Trap” and “The Battle Over Health Care: What Obama’s Reform Means for America’s Future” (Rowman & Littlefield, April 2010). She serves as a section editor for the Archives of Internal Medicine Series “Less is More”).
