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Hospice: an effective program that saves money.

The Centers for Medicare and Medicaid Services (CMS) has recently revised rules that speak to physician participation in the care of patients on hospice. The rules are onerous and threaten the success of one of Medicare's most popular and successful programs.

Medicare specifies that the care of hospice patients be under the supervision of a team physician (a team consists of a physician, nurses, certified nurse assistants, a chaplain, and a social worker). The team meets weekly to discuss patients, identifying new problems and planning appropriate interventions. The team also reviews patients who are living longer than their disease would predict and weighs whether the patient remains eligible for hospice services. This is the recertification process, and it is the means by which Medicare determines whether patients continue to benefit from these specialized services meant for the care of patients at the end of their lives. It is a legitimate function that all insurers, private or public, conduct for all the services they provide.

Prior to April 1, 2011, there was no requirement that physicians actually see and examine the patients on hospice. Under the new rules mandated by the Affordable Care Act, there is still no requirement that physicians see patients newly admitted to hospice. However, the ACA "requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patient's 180thday recertification, and each subsequent recertification" These "recerts" occur every two months, and it isn't unusual for terminal patients to outlive the six-month prognosis that provided the original basis for admission to hospice. Therefore, the "visit load" for hospice physicians has increased markedly.

The great majority of hospice patients are at home or in nursing homes. Hospice physicians, mostly part-time doctors with practices of their own, in order to preserve the hospice benefit for dying patients, now have to commit a great deal of travel time to lay eyes on a patient for these "face to-face" encounters. The trips often serve no purpose--the patient has no need for an acute medical intervention (for example, an increase in narcotic dosage), and has a disease (for example, lung cancer that has spread to the bones, liver, and/or brain) for which no one would question the appropriateness of continued eligibility for hospice services. These "recertification trips" use up the valuable time that hospice doctors could be putting to use for better purposes, and Medicare doesn't pay for this activity. Many larger hospices are reimbursing their physicians for these newly mandated visits, but smaller ones (particularly rural ones), are often unable to mobilize the physician person power for this recertification function. The new rules are already threatening the viability of these smaller operations.

By making ongoing eligibility for hospice services more restrictive, the new policy is, of course, designed to save money. The CMS denies this, saying that the initiative is designed to improve the care of patients on hospice. If this were true, a more effective intervention would be to require hospice doctors to see patients upon admission to hospice. Regardless, the new rule is misguided.

The purpose of the hospice service is to provide end-of-life comfort care for the terminally ill and support of the dying person's loved ones. It's a wildly effective program with satisfaction ratings that are off the charts. But it also saves the healthcare system an enormous amount of money. The cost-effectiveness of hospice is only incidental to its overall mission, but what an incidental it is.

Investigators at Duke University have recently shown that Medicare expenditures for hospice patients averaged $2,309 less during the last year of life, compared to patients who did not use hospice ($7,318 versus $9,627, over the period of 1993-2003). The reason for the savings is that, compared to non-hospice users, hospice patients avoid expensive and often ghastly hospital-based terminal care. Instead, by their own choice, they receive care that is effective, appropriate, and humane in a residential setting. Almost 1.5 million patients use hospice care each year, and this represents a savings to the healthcare system of over $3 billion annually.

Medicare is right to closely examine costs, for there are many bloated expenditures in our healthcare system. But the hospice benefit isn't one of them. Compliance with the new rules is very difficult, and implementation is tending to reduce the number of people in the United States under hospice care. It will therefore increase the overall cost of medical care and deprive some terminally ill patients of the benefits of one of Medicare's most effective programs. Rather than promulgating regulations that essentially restrict participation in the hospice benefit, Medicare should be looking to formulate policies that increase the number of patients under hospice care.

James Whalen is a physician with experience in academic medicine, research, and hospital administration. He is currently a hospice physician, serving as a team physician in Chicago's western and northern suburbs.
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Title Annotation:Up Front
Author:Whalen, James P.
Publication:The Humanist
Geographic Code:1USA
Date:Nov 1, 2011
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