Hospice Care: Too Costly or Misunderstood?

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

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What the Public Thinks about Medicare and the Deficit

This week, the website of the New England Journal of Medicine includes a report by Harvard researcher Robert Blendon and colleagues on “The Public’s Views on Medicare and the Budget Deficit” based upon an analysis of 21 opinion polls. Their conclusions include that the public believes the budget deficit to be serious but does not think the way to solve it is by cutting Medicare.

I’m not sure what the freshmen members of the House of Representatives think of such sentiments but in 1995, Newt Gingrich was reported to have said in a speech to Blue Cross/Blue Shield about Medicare, “We don’t get rid of it in round one because we don’t think that would be politically smart, and we don’t think that is the right way to go through a transition. But we believe it’s going to wither on the vine because we think people are going to voluntarily leave it.” Medicare has been a highly successful program and, according to this recent analysis of opinion polls, continues to be highly popular among beneficiaries. With the Medicare-eligible population burgeoning, the program needs to be reformed–as does our whole health care system. We’re spending too much money in the last few weeks of life without producing satisfactory end-of-life experiences for many patients and their families. We rely too much on acute care and not enough on health promotion and better managing chronic illnesses.

The analysis by Blendon and colleagues indicates that the public would rather raise taxes on the wealthy than cut Medicare, reduce aid to foreign countries, reduce military spending, and increase taxes on corporations. One wonders what the freshmen members of Congress must be thinking. Is the aim to cripple government and Medicare to achieve Gingrich’s prediction? Their mantra is that the people elected them to radically change the role of government and how Washington works. Perhaps some did. But for many older Americans and those approaching Medicare eligibility, the message from opinion polls is “hands off my Medicare!”  We need to move agressively on the opportunities in the Affordable Care Act for transforming how and what care is delivered and paid for under Medicare.

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

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Leap Frog Group Embraces Magnet Designation

For a long time, I was disappointed in the Leap Frog Group, the consortium of businesses that sought to leverage its clout to improve the quality and safety of health care. They set standards for health care organizations to meet but initially failed to include nurse-sensitive indicators of quality. While they have made some progress on this over the years, the Institute of Medicine‘s report on The Future of Nursing appears to have informed Leap Frog’s decision to include Magnet designation as an indicator of quality. This designation is bestowed by the American Nurses Credentialling Center, an affiliate of the American Nurses Association. It is an indication of excellence in nursing care. While not a perfect process, it is the best method we have to determine whether a hospital is providing high quality, safe nursing care. Since patients are admitted to hospital because they need nursing care (most are treated on an outpatient basis if 24-hour nursing care is not needed), Magnet designation is often times a proxy for overall excellence in patient care.  Nice to see the Leap Frog Group leap forward.

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

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