• Hospice Policy-What is the Problem?

    Chris Langston in the Hartford Foundation’s health AGEnda blog has a nice post summarizing some basic information on hospice and asking what are the key policy questions that need to be addressed. This new flurry of hospice discussion has been sparked by the recent NY Times story on for profit hospices, along with research peer review research that also raises questions about profit status and the delivery of hospice care. There are several big picture policy issues as I see them:

    • Medicare hospice policy needs to be updated because the basic regulations are unchanged since 1983. In particular, the language of having to ‘unelect curative care’ in order to access hospice makes no sense. If we could ‘cure’ the disease in question we would. What they meant was you have to unelect ‘the default in the health care system which is aggressive care.’ We need to modernize the language.
    • We need to get straight the distinction between hospice and non-hospice palliative care. Non-hospice palliative care could be viewed as care that addresses symptoms regardless of prognosis. Hospice is a subset of palliative care that is for persons who are believed to be in the last 6 months of their life.
    • We need to move toward concurrent palliative care, which means addressing symptoms before a person is viewed as ‘dying’, but do this in a way so that CMS doesn’t think that what we are actually doing is developing a back door long term care benefit. This is a key issue since ~90% of hospice paid for by Medicare is provided to people in their homes.
    • We need to determine the linkage between use, cost and quality of all of these services. Most research has looked at use and cost, or use and quality of hospice or palliative care. You need to know all three to be able to evaluate the appropriateness of care or to determine if it is ‘working’ or ‘worth it.’ I have two research studies underway on this, and hope to have preliminary results in the Fall.
    • Note that for a variety of reasons, including the fact that the introduction of the hospice benefit in the early-1980s was sold at least partly on the basis that it would not increase overall Medicare costs and so would ‘save money’, hospice care in particular has been evaluated differently from just about everything else that Medicare pays for. For example, no one asks if a new chemotherapy, or a left-ventrical assistive device improves quality AND SAVES MONEY. The question is does it improve QOL and/or extend life and how much does it cost to do so. There is nothing else that Medicare purchases that I can think of that is expected to provide benefits AND SAVE MONEY. I realize I have helped to drive this expectation by publishing papers such as this.
    • All of this has to be done in the current political environment in which when in doubt, politicians accuse their opponents of wanting to ration care, kill my grandmother, etc. Shocking as it may seem, this does not help us develop better policy.
    • Great comments.
      Agree the current benefits need a significant work over.
      Also having patients sign that they understand what is going on with the switch from curative intent is clearly wrong.

      • @Jim Cleary
        the evidence is available for us to greatly improve policy. I think the political/cultural context of our time makes it hard because of the death panel meme. However, hospice and palliative medicine are the parts of the system with most experience of listening to patients and trying to maximize quality of life and life extension and being able to talk about tradeoffs in how therapies may or may not contribute to these. The entire system has to move this way and palliative care/hospice can play a key role in leading the way.