Medicare to test allowing more than palliative care in hospice
■ The new health reform law also orders Medicaid and CHIP plans to cover "concurrent care" for terminally ill children.
New changes to Medicare and Medicaid payment could address the emotionally wrenching dilemma faced by physicians and terminally ill patients forced to choose between continuing curative treatments and taking advantage of hospice care programs' in-home palliative, psychological and spiritual services.
The health reform law enacted in March directs state Children's Health Insurance Programs and Medicaid plans to immediately cover "concurrent care" -- a combination of curative efforts and hospice care -- for children with terminal illnesses. The Congressional Budget Office estimates that the expanded coverage will cost $200 million over 10 years.
The law also calls on the Health and Human Services secretary to conduct a three-year, budget-neutral demonstration project of concurrent care for Medicare patients at 15 hospice-care sites.
The use of hospice and palliative care has grown steadily in recent years. Nearly 1.5 million patients received hospice care in 2008, up 36% from 2004, according to the National Hospice and Palliative Care Organization, which represents 80% of the country's hospices. Yet physicians offering this alternative to patients often receive hostile responses from patients and families who view it as the final step through death's door.
"There are people who, when talking about hospice, they'll say, 'Don't say that word in front of my loved one,' " said Christian Sinclair, MD, associate medical director of Kansas City Hospice & Palliative Care in Missouri. "We get such a visceral reaction to changing toward a palliative care goal."
Choosing hospice care can be especially scary for patients on Medicare, said Diane E. Meier, MD, director of the nonprofit Center to Advance Palliative Care. Some private health plans cover concurrent care, but for Medicare patients -- and, until recently, children covered by Medicaid -- choosing hospice has meant giving up aggressive treatment efforts.
"The Medicare hospice benefit is the jewel in the crown of Medicare in that it's truly interdisciplinary care," said Dr. Meier, director of the Hertzberg Palliative Care Institute at New York's Mount Sinai Medical Center. "But in order to get this wonderful benefit that is hospice, you must, on the flip side, sign a form giving up the right to regular Medicare. People feel, quite rightly, that it's like signing a death certificate."
Dr. Meier notes that it takes only a day to process the paperwork for leaving hospice and re-entering regular Medicare. But the idea of enrolling in hospice in the first place and "giving up" on life still frightens patients and families, leading them to delay use of hospice.
The median length of stay in hospice is less than three weeks, and one-third of hospice patients die within a week of being admitted, said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization. He said that Medicare paying for concurrent care could make it easier for patients and families to move from aggressive treatment to palliative care.
"You go from one phase to the next phase with something to hold on to as you make that transition," Schumacher said. "Many people say, 'I wish I'd come to hospice sooner.' "
Getting patients into hospice earlier gives them access to expert advice to help decide whether curative efforts are worth pursuing further, Schumacher said. "We believe involving hospice sooner will help people forgo nonproductive treatment."
The demonstration project will test whether paying for concurrent care helps patients and saves Medicare money. Then the HHS secretary will recommend to Congress whether to change the hospice-care payment policy. A Centers for Medicare & Medicaid Services innovation center created in the health reform law also may be able to act on the recommendations. Hospice care cost Medicare $11.2 billion in 2008, according to the Medicare Payment Advisory Commission.
In the meantime, children with terminal illnesses and their families should benefit from Medicaid's coverage of concurrent care efforts, Dr. Sinclair said.
"In pediatrics, the prognosis for patients can be a lot harder to define," he said. "Having a concurrent care model is helpful, because those families need a lot of help, especially from psychosocial and the other resources that hospice can provide."