Hospice Care: Too Costly or Misunderstood?

Three Ages of the Woman and the Death by Hans Baldung-Grien

Recently, there have been some reports of increased Medicare spending on hospice care.  For example, Jordan Rau of Kaiser Health News  reported on for-profit facilities taking advantage of the payment approach to hospice care under Medicare and keeping patients on hospice care for more than the 6-month limitation of service (patients can be re-certified if they live beyond the first 6 months). He reported, “Medicare’s bill for hospice care rose to more than $12 billion in 2009 from $2.9 billion in 2000. Although the benefit is intended for patients who have no more than six months to live, 19 percent now receive hospice services for longer.”

Christopher Langston,  Program Director for the John A. Hartford Foundation, provides a thoughtful commentary on the rising chorus of voices that suggest spending on hospice care is out of control. Certainly,  long-term hospice care needs to be examined, particularly by for-profit hospices that appear to seek out patients who are not seriously ill and keep recertifying them for the benefit. But so many people don’t understand hospice care or are not advised early enough to seek it that it’s grossly underutilized.

For example, I’ll never forget rounding with the medical team at Beth Israel Medical Center in New York City in the 1990s. The team was seeing a 60-something man who was diagnosed with metastatic cancer. The results of his most recent tests had come in and indicated that the metastasis had spread uncontrollably. As the medical team discussed various treatment options to try to stop or slow the cancer–most of which had adverse effects that could compromise the quality of his life worse than the cancer–I asked whether the team had discussed hospice care as an option. The chief medical resident curtly replied, “We’re not at that point yet. Besides, we wouldn’t discuss that with him. His private physician would.”  So they proceeded to “treat” him without mercy, holding out the hope that they would be able to extend his life without saying for how long and at what cost, physically and financially.  As New York Times columnist David Brooks wrote in a July 15th column about “Death and Budgets“, “…we think the budget mess is a squabble between partisans in Washington. But in large measure it’s about our inability to face death and our willingness as a nation to spend whatever it takes to push it just slightly over the horizon.”

Amy Berman knows only too well about this situation. She’s also at the John A. Hartford Foundation as a Senior Program Officer and blogs about her own experience with incurable cancer. Her most recent blog post discusses the reluctance of health care providers to talk with patients about end of life options.

In Part II of his blog on hospice care, Langston discusses the new Medicare regulations that are designed to tighten up on extended stays in hospice. He rightully challenges whether making recertification for hospice care more difficult is better than extending the benefit to 9 months and pursuing different payment arrangements that de-incentivize the facility or agency from premature admissions. Until we correct the fact that 67% of hospice enrollees fail to get even 3o days of hospice care (what Langston notes is referred to as “the minimum effective ‘dose'”), perhaps we should be finding ways to encourage hospice admissions for people who no longer pursue curative care–regardless of how long they have to live.

Diana J. Mason, PhD, RN, FAAN, Rudin Professor of Nursing and Co-Director, CHMP