Hospice focuses on caring for people physically, socially, emotionally and spiritually throughout their end-of-life treatment. The hospice philosophy is holistic supporting not only the person but the entire family. Medicare covers hospice for individuals with an incurable illness most likely limiting their lives to less than six months based upon a physician’s diagnosis. The Medicare Handbook states that the benefit includes covering drugs for symptom control and pain relief, medical and support services from a Medicare-approved hospice, and other services not otherwise covered by Medicare such as grief counseling. The care may be given in your home or a nursing facility if this is where you currently reside and in an inpatient hospice facility. Medicare hospice care also covers some short-term hospital and inpatient respite care to relieve a caregiver.
Even though millions would benefit from hospice care every year, large numbers walk away from the service because they don’t want to make the choice of either accepting hospice or rejecting life-extending care. “For too many of those patients, “that’s not hospice; it’s last rites,” counters Dr. John W. Rowe former CEO of Aetna in a recent NYT article. Regretfully, many people believe signing up for hospice care is a sign of giving-up all hope, so they hold-off making the choice and lose the opportunity to receive emotional guidance, pain management, and coordinated care during the most heart wrenching time of their lives.
Medicare beneficiaries can sign-up for hospice care, opt out in the middle of that care and then rejoin later with no waiting period imposed. For example, you may have advanced breast cancer and are receiving hospice care but you’re offered a round of radiation therapy to slow down the growth of a tumor that could hopefully extend your life by months. In this instance, you may decide that you’d like to try the radiation therapy forcing you to end your relationship and care with hospice. Or, perhaps a blood transfusion would bring you much needed energy and you’d like to enhance the quality of your remaining time. The revolving door approach is confusing to families and patients and greatly increases the likelihood of them falling through the cracks in an already fragmented system.
But times are changing. A growing number of hospice providers, experts and insurers believe that this either-or choice is unfair and outdated given new medical advances that were not available since Medicare began covering the benefit over twenty years ago. Hospices throughout the country and locally are exploring an “open access” concept allowing patients to receive the palliative care of medical and social support that have become the hallmark of hospice care and be given access to medical advances that can slow down the course of their disease. “We’ve had a few patients receive treatment such as radiation and chemotherapy while in our hospice and we’ve seen other hospice programs throughout the country exploring this new approach, too,” reports Karen Paris, LSW and Director of Hospice of Central Pennsylvania. “Its goal is to help patients make transitions in their care rather than make an either/or choice.” Open access proponents believe they will be better able to support patients and families struggling with a life-limiting illness who do not wish to discontinue certain treatment regimens.
But Medicare officials contend that if people can receive both curative medical care and palliative (soothing) care at the same time, then their costs will soar. Yet those in the field report that patients who are not in hospice tend to use emergency rooms much more because they don’t have the 24/7 advice of nurses and doctors who understand the course of the disease and can help families care for someone at home. As a result, patients end up in the hospital at much higher costs to Medicare and in the least favored setting for a dying person. Medicare doesn’t ban a hospice from offering advanced medical care – they just won’t pay for it. But what hospice provider can afford including chemotherapy or other advanced medical procedures on a $130 per diem rate for routine care no matter what the patient’s condition?
The other side of the debate is philosophical. If hospice’s mission is to bring holistic care and comfort to those who have accepted that their life is coming to a close then embracing treatments seen as life-saving or prolonging undercuts that acceptance. It sends mixed messages and interferes with their spiritual and psychological development towards achieving a peaceful dignified death. And it seduces families into accepting futile and unrealistic attempts that deny the inevitable.
YOUR TURN
Should Medicare stop forcing people to choose between hospice care and advanced medical care intended to prolong their lives? Or does the system work well as it stands now allowing people to opt out whenever they want and rejoin when they need to?
