J. Donald Schumacher
First posted 7/5/11 on Kaiser Health News
The author is responding to a recent Kaiser Health News story: Concerns About Costs Rise With Hospices’ Use (Rau, 6/27).
As Congress works to come to terms with the economic challenges facing our nation, it’s inevitable that discussions focus on health care. With an estimated one third of Medicare spending going towards care of beneficiaries in the last year of life, attention has understandably turned to the rising costs of hospice care. Hospice is the leading provider of palliative care services for those facing serious and life-limiting illness.
Admittedly, there has been much growth over the past decade, from 700,000 patients receiving care in 2000, to more than 1.5 million people now. Current Medicare spending on hospice has increased to nearly $12 billion. Utilization of hospice and the costs of care have increased due to a variety of factors affecting the field.
In 2000, the majority of those served by hospice had some form of cancer, where the expected trajectory of the illness — and the associated costs — was more predictable. Today, less than 40 percent of hospice patients have cancer. Hospice providers are serving more patients with complex illnesses — such as those with late-stage dementia — who have uncertain trajectories making prognosis much more difficult.
A decade ago, a patient’s home was almost always the primary place where care was provided. While the private residence is still the primary location of most care in the US, today, hospice care also is provided in nursing homes, assisted living facilities, hospitals and residential facilities.
And perhaps most importantly, in 2000, for every person that received hospice care, there were two other dying Americans who would have benefitted from this compassionate, quality care but did not get it.
We’ve made progress in caring for the dying. Yes, costs have increased, but so has the number of dying Americans cared for by hospices.
Hospice leadership has repeatedly called for more consistent and timely oversight of providers. Currently, hospices are surveyed on average every six to 12 years. NHPCO supports legislation introduced in the Senate mandating CMS surveys of hospice programs at least every three years.
Additionally, despite the significant administrative burdens and additional costs imposed on hospice providers, NHPCO, along with other hospice membership organizations and providers across the nation, worked in a cooperative fashion with CMS to ensure the orderly and timely implementation of the new Face-to-Face Encounter Rule. NHPCO supported the new regulatory requirement that a patient’s record include a physician narrative. Additionally, there was support for the new requirement for enhanced medial review of claims for patients with stays exceeding 180 days.
These additional requirements, coupled with reimbursement cuts, strain the ability of hospice programs to be able to keep their doors open, yet the hospice community continues to support their implementation.
Well before health care reform, a voluntary Quality Partners program with self-assessments and other resources and tools to assist providers with quality measures and performance improvement was created by NHPCO. The hospice community has supported CMS efforts to collect more patient-level data and has gone on to specifically request collection of a broader range of data.
In addition, NHPCO has consistently supported the “aggregate financial cap” which places a limit on the amount of Medicare payment for all Medicare beneficiaries served by a hospice in a year.
The focus by MedPAC, Congress, and CMS on patients with longer lengths of care is certainly understandable given the need to cut our nation’s health care expenditures (NHPCO research shows that in 2009, 11.8 percent of patients remained under hospice care for longer than 180 days). However, there are concerns that MedPAC, Congress and CMS have ignored the other end of the spectrum, offering no solutions to the incredibly short median length of stay of 17 days which has not changed in a decade.
Far too many Americans begin hospice care too late in the course of their illness. We know the reasons why people are referred to hospice so late. Besides the reluctance of physicians to “give up” on their patients, there is confusion surrounding Medicare’s “six month” eligibility requirement for hospice enrollment. This requirement is often misinterpreted to mean that Medicare expects a patient to have six months or less of hospice care. The Medicare benefit does not place a limit upon how long a person can receive care. If a physician certifies that a patient is likely to die within six months, they are eligible for hospice care as long as they need it.
Some who question the growth of hospice use illustrations of outliers, such as those providers who have failed to meet compliance standards or the case of patients who may have stayed under the care of hospice for multiple years. However, it’s dangerous to paint the entire field by the actions or experiences of a few, as it gives an inaccurate perception to the public and to policy makers. Are there some hospices that are “bad apples”? Yes. But that is the outlier, not the norm. NHPCO and the overwhelming majority of providers in the field want to see bad providers closed down.
Quality and cost — those are two drivers of all our talks about fixing health care. The overwhelming majority of hospices are committed to providing the highest quality care possible. And research has shown that for every Medicare beneficiary that utilizes hospice, Medicare saves about $2,300. In an atmosphere of reimbursement cuts, with average net margins of less than three percent (according to MedPAC statistics), the hospice community remains a costs effective and fiscally responsible high quality end-of-life provider.
J. Donald Schumacher, PsyD, is the President and CEO of the National Hospice and Palliative Care Organization.