Hospices May Be Discouraging
Patients with Expensive Medical Needs
Medicare pays for most hospice care
and a patient's doctor and hospice medical director must certify patient
has 6 months or less to live; patients must agree not to seek
Jan. 23, 2013 - Many people who are
terminally ill delay entering hospice care until just a few days or
weeks before they die, in part because they or their families don't want
to admit that there's no hope for a cure.
"It's a hard decision to say yes
to," says Jeanne Dennis, senior vice president at the Visiting
Nurse Service of New York, which provides hospice care to 900
patients daily, among other services. "Everybody knows it means you're
not going to get better."
study published in the journal Health Affairs found that
there may be another reason that patients don't take advantage of the
comprehensive services that hospice provides: restrictive enrollment
policies that may discourage patients from signing up.
The survey of nearly 600 hospices
nationwide found that 78 percent had enrollment policies that might
restrict patient access to care, especially for those with high-cost
medical needs. The policies included prohibitions on enrolling patients
who are receiving palliative radiation or blood transfusions or who are
being fed intravenously.
qualify for hospice care under
Medicare, a patient's doctor and a hospice medical director must certify
that the patient has six months or less to live. Patients must also
agree not to seek curative care.
Once a patient chooses to enter
hospice, the benefits include medical treatment for non-curative
purposes such as pain and symptom management as well as emotional and
spiritual support for patients and their families. Most patients receive
hospice care at home.
The Health Affairs study points out
that some treatments typically considered curative also may be used to
manage the symptoms of a dying patient. For example, someone might
receive radiation treatments to shrink a tumor to make breathing easier
or be given a blood transfusion to reduce fatigue.
But such care can be expensive,
costing upward of $10,000 a month, according to the Health Affairs
study. That puts hospices in a financial bind. Last year, the Medicare
program paid a base rate of $151 per day to cover all routine
hospice services, adjusted for geographic differences.
"It's a fixed, per-day cost that
doesn't relate to the complexity of care provided," says the lead author
of the study, Melissa Aldridge Carlson, an assistant professor of
geriatrics and palliative medicine at New York's Mount Sinai School of
Large hospices that care for more
than 100 patients are better positioned to absorb the cost of such
treatments, experts say.
"They've got the economy of scale
to be able to manage high-need patients," says Diane Meier, director of
to Advance Palliative Care in New York and a professor of
geriatrics and palliative medicine at Mount Sinai. "Smaller hospices
don't have that luxury."
Nearly two-thirds of hospices care
for 100 or fewer patients per day, according to the National Hospice and
Palliative Care Organization.
"It gives us the capacity to not be
completely money-driven, so we can afford expensive treatments," says
Gretchen Brown, the chief executive.
Still, hospice operators walk a
fine line sometimes in distinguishing between palliative and curative
care. Medicare reviews their work closely, Brown says, and sometimes raises
questions when patients are in hospice care longer than six
"We really can't pay for something
that's going to cause someone to live longer than six months," she says.
Worries that Medicare might deny
coverage for a certain treatment is truly palliative rather than
curative may contribute to smaller hospices' more restrictive enrollment
policies, as the study found, Carlson says.
"The risk is that . . . they'd have
to return the money," says study author Carlson. "So for a small
hospice, it's very risky to enroll a patient who has these needs."
Some experts question whether
smaller hospices actually do turn away patients with expensive needs,
even if their enrollment policies suggest they would deny enrollment to
"Yes, the hospice may have [such]
policies, but the study wasn't clear to what extent those policies
impact admissions," says Jon Keyserling, senior vice president for
health policy at the National Hospice and Palliative Care Organization.
As a patient or concerned family
member, the important message is that all hospices are not alike, Meier
says. If you encounter a hospice that won't provide the care you need,
"it's worth your time to explore others, particularly those that have
more than 200 patients a day," she says.
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