Caregiver & Elder Care News
Medicare Experiment Could Signal Sea Change for Hospice
What is hospice care? How does it differ from
palliative care? And. curative care? Being changes in
care for oldest and sickest Americans
Michelle Andrews, KHN Writer
30, 2014 - Diane Meier is the director of the Center to Advance
Palliative Care, a national organization that aims to increase the
number of palliative care programs in hospitals and elsewhere for
patients with serious illnesses. Meier is also a professor of geriatrics
and palliative medicine at the Icahn School of Medicine at Mount Sinai
in New York City. We spoke about a recently launched pilot program under
the health law that allows hospice patients participating in the pilot
to continue to receive life-prolonging treatment. This is an edited
version of that conversation.
Q. There’s a lot of confusion
about how hospice
care differs from palliative care. Maybe we should start by clearing
up what those terms mean.
A. The short, quick elevator answer
is that all hospice care is palliative care -- but not all palliative
care is hospice. Palliative care is a team-based type of care focused on
maximizing the quality of life for people and their caregivers at any
stage of illness. It focuses on treating the pain, stresses and symptoms
of serious illness. The emphasis is on need, not prognosis or how long
you might have to live.
In contrast, the
hospice benefit, which was written into the Medicare statutes about
25 years ago, had a number of limits in it to control spending.
First, two physicians have to
certify that the patient will likely be dead in six months if the
disease follows its natural course. Second, the patient or family
members need to sign a paper giving up regular insurance coverage for
disease treatment in order to get access to hospice, a forced either/or
choice between life-prolonging treatment and palliative care. It was an
attempt to save money. Most people need—and want—both types of
But we can’t predict who’s going to
die in six months, in part because of the variation in people. We can’t
really tell if someone is going to keep motoring along. The other thing
is that many people want to keep receiving disease treatment, because it
is helping them to get along and keeping up their quality of life. As
someone who has counseled many people with serious illnesses, I can tell
you it is very painful to tell people they have to sign away their
rights to treatment. It’s like hitting a man when they’re down.
Q. The Centers for
Medicare & Medicaid Services recently announced that the agency is
launching the Medicare
Care Choices Model, a program created under the health law that
allows hospice patients with advanced cancers, chronic obstructive
pulmonary disease, congestive heart failure and HIV/AIDS to receive not
only hospice care but also curative care.
Does this experiment signal a
noteworthy change in approach toward caring for dying patients?
A. I think it does. I think it's a
recognition that this forced choice between palliative care and
life-prolonging treatment is irrational.
Unfortunately the way
the new benefit was written is that the only people who can be eligible
[for the pilot] are those who would be eligible for hospice, that is,
people very likely to be dead within a few months. People tend to be
pretty damn sick by the time they become eligible for hospice. I’m not
really sure what access to curative care means in that context. If these
patients could have been "cured" they wouldn't be eligible for hospice.
It’s a misnomer to say they’re
going to be cured. There are very few diseases that we cure in
U.S.medicine. In most cases what we’re talking about is life-prolonging
treatment, and in most cases that’s palliative treatment. It makes
people feel better. If you have emphysema and I give you broncodilators
and steriods to open up your airways, it will prolong your life, and it
will also make you feel better.
Q. I understand that some
hospices say they won’t participate in the new program because the CMS
payment rate of $400 per beneficiary per month isn’t enough cover their
costs, which include coordinating beneficiaries' care with curative and
other providers, and providing counseling and support services for
beneficiaries and their families (curative care services are covered by
the regular Medicare program). Is that rate too low to provide the
A. You can do something that’s
fairly telephone intensive for $400. You can have staff get training in
symptom management and have them talk to family members, which are
usually the ones who are calling with questions. The problem is if you
have to dispatch a human being to the person’s home. It’s difficult
to do that for $400. And when someone calls after hours you often need
to do that. It’s really hard to provide 24/7 visiting capacity with that
amount of money.
Remember: These patients are not
stable, they are the sickest patients in our health care system. They
need a lot of hand holding. Availability and responsiveness are key
and that’s expensive.
The patients in this demonstration
project may be much more complicated to take care of than regular
hospice patients. Not only are they dealing with the conseqences of
disease but with the consequences of treatment, the side effects of
chemo, for example. Hospice staff are not accustomed to working with
patients who want continued disease treatment.
I think it’s going to be
challenging but I think it will lead to some really creative solutions.
Hospice organizations may look to build out a more comprehensive safety
net by partnering with other community providers like Meals on Wheels or
local aging services or transportation providers. And that would be
Q. What does the research show
about people who receive both hospice or palliative care and
A. There are now several studies
that show that patients who receive both palliative care and
life-prolonging care actually live longer than those who receive
life-prolonging treatment alone.It makes sense. People aren’t in
excruciating pain, they’re not depressed, their families feel confident
in their ability to care for their loved one. And if, very importantly,
people are able to avoid the very real risks of hospitals, it’s no
surprise that they live longer.
They’re not getting less
life-prolonging treatment with palliative care, they’re having less
crisis. They reduce emergency care use because they don’t need it and
that saves money.
If palliative care were a drug, I’d
Q. What could that mean for this
new CMS pilot program?
A. Let’s say hospices can do this
for $400. Think about the pressure to scale that up to people whose
prognosis is two years or three years or even longer.
So I can see why CMS is being
really cautious. It’s going to be important to demonstrate that if you
take people and do this, that it won’t break the bank. My prediction is
that it will actually be less expensive to provide both approaches at
the same time precisely because it will lead to less need for costly
emergency and crisis care.
Q. What’s next on the horizon
for palliative care?
A. We’ve gotten pretty far with
integrating palliative care into hospitals. More than 60 percent of
hospitals with more than 50 beds nationwide have programs. But most
people are living at home. Right now it’s very hard to access palliative
care if you’re not on hospice or in the hospital. In the next 10 years,
we need to integrate palliative care into home care, cancer center care,
dialysis units, nursing homes and other settings.
Note: More about Diane Meier
the director of the
Center to Advance Palliative Care
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