Brooke Delaney Issues in Health Policy and Management Policy Issue Examination

The Imperative for Extended Hospice Eligibility The period at the end-of-life is currently not effectively managed in the United States. Study after study shows doctors and other medical providers illprepared to handle the suffering associated with the end of life, especially pain. Moreover, referrals to palliative care and hospice programs lagging far behind the actual demand for the services. These demands include not just symptom management, but also treatment for pain, nausea and vomiting, delirium, anxiety, and other unpleasant symptoms, as well as psychosocial needs. In addition to making physicians more sensitive to their patients preferences for cardiac resuscitation, choice in heath care proxies, and wishes regarding ventilator dependence, more attention and access needs to be created to allow for more effective utilization of hospice care available so that the maximum number of terminally ill patients can take advantage of the services. The hospice model of care is a multidisciplinary approach to terminal illness that stresses palliation rather than cure and incorporates family and volunteers into the patients physical care and psychological support. The lions share of legislation related to hospice care takes place at the federal level. As outlined in the federal Medicare legislation of1982 (Medicare Hospice Benefits 2000) and reinforced by the Medicare General Information, Eligibility, and Entitlement Manual, a patient is considered eligible for benefits if the prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal

course. (NHPCO 2008) If the patient thrives beyond the initial benefit period (comprised of two 90-day intervals), Medicare requires evaluation and recertification for extension of coverage every 60 days. In addition to being subsidized by Medicare and Medicaid (100% coverage with no co-pay or deductible by Medicare Part A excepting respite care and pharmaceutical copays) (Medicare Hospice Benefits 2000), a majority of commercial insurance companies will pay for the hospice support services that are aimed at keeping the patient as comfortable as possible. Each hospice organization is individual and, in essence, a singular entity with its own policies related to payment for services. Additionally, once an individual is enrolled in a hospice, that hospice becomes responsible for insurance for all subsequent related conditions and hospice-related illnesses. One of the major principles of hospice to offer services based upon need rather than the ability to pay. Many hospices rely upon community support for donations to provide for patients without sufficient funding or coverage. According a report by to the National Hospital and Palliative Care Organization in 2008, 58.3% of hospice agencies were independent entities, 20.8% were hospital based, 19.7% were home-based and 1.3% were based within a nursing home facility. As stated, federal policy stipulates that in order for a patient to be eligible for hospice services, the prognosis must be 6 months or less. In many instances it may be difficult to pinpoint precisely how long a patient might live. Hence, some physicians are hesitant to give a definitive prognosis, might be overly cautious about the patients emotional well-being and optimism to give a short

prognosis, or believe that the 6 month terminal prognosis must be exact. For this reason, most patients do not take advantage of hospice care until the very endof-life. In New York State median length of stay ranges from is approximately 17 to 19 days. (HPCANYS 2011). For fiscal, managerial and ethical reasons, it behooves policy makers at both the federal and state level to lobby for a change in definition from 6 months to 12 months for hospice eligibility. Hospice patients are usually much more satisfied with their care and have fewer unmet needs than those not in hospice. Hospice patients also cost Medicare less than those not in hospices. About one third of health care costs occur in the last months of life (Gawande). That said, it is promising that nation-wide hospice expenditures from Medicare are up 70% from 2005 to 2009. (Morrison, et. al.) Patients facing serious or life-threatening illnesses account for a disproportionately large share of non-hospice Medicaid spending. In a study of New York Hospitals taken between 2004 and 2007, data showed that patients who received palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. Additionally, these reductions included $4,098 in hospital costs per admission for patients discharged alive, and $7,563 for patients who died in the hospital. (Morrison et.al.) In keeping with the ethical aims of the hospice philosophy and wishes of patients and families, palliative care patients spent less time in intensive care and were less likely to die in intensive care units. Sacco estimates that the reductions in Medicaid hospital spending in New York State could eventually range from $84 million to $252 million annually (assuming that

2 percent and 6 percent of Medicaid patients discharged from the hospital received palliative care, respectively), if every hospital with 150 or more beds had a fully operational palliative care. States including California and Florida have already adopted the 12 month definition for eligibility and New York State is presently lobbying for the same, as is evidenced by the Medicaid Redesign Teams February 25, 2011 Report which included a recommendation to expand hospice (MRT #209), including changing the definition of terminal diagnosis from 6 months to 12 months. The proposed legislation would implement the Medicaid Redesign Teams recommendation, which has been accepted by the Governor and the Legislature. (HPCANYS 2011). Ideally, this definition would expand at the federal level, creating a new blanket standard for eligibility on a nation-wide basis with less need for recertification or state-by-state discrepancies. There is not much dissent regarding policy between the sate and federal governments, but given that the majority of coverage is under the auspices of Medicare, and that there is little room for relative differences in need on a local level, it is best if the federal arm took the lead in policy change. This would benefit the taxpayer as well as privately funded hospices as the proven cost-cutting effects of the program would be more widespread. Certainly policy makers as well as shareholders must be cautious with language when it comes to end-of-life policy, but I do not believe that there is any arguable benefit to maintaining the current terminal definition of six months. Proper and farther-reaching utilization of hospice services will

streamline over-bloated costs that are poured into futile treatments, increase the quality of life for the patient, and set a strong precedence for additional reform.

References Care of Chronic Illness in Last Two Years of Life. The Dartmouth Atlas of Health Care. n.d. Web. 30 Sept. 2011. Center to Advance Palliative Care. (2011). Americas Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nations Hospitals . Retrieved from http://www.capc.org. Gawande, Atul. Letting Go. The New Yorker. The New Yorker. 2 Aug. 2010 Retrieved from http://www.newyorker.com HPCANYS: Hospice and Palliative Care Association of New York State: Memorandum of Support A. 7650S/S. 5554. (2011) Retrieved from http:// www.hpcanys.org/. Morrison, R.s., Dietrich, J., Ladwig, S. Quill, T., Sacco, S., Tangeman, J., Meier, D. (2011). Pallative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficaries. Health Affairs, 30, 454-463. NHPCO facts and figures: Hospice care in America. Alexandria, Va.: National Hospice and Palliative Care Organization. October 2008. "Medicare Hospice Benefits". Medicare, the Official U.S. Government Site for People with Medicare. March 2000. Retrieved from http://www.medicare.gov