Given the ever-escalating costs of care for those in the last year of life, it’s no surprise that Congress, MedPAC and the Centers for Medicare and Medicaid Services continue to search for ways to curb those costs. What is surprising, and in fact perplexing, is the focus on the one aspect of end-of-life care that we know saves money and improves the quality of those who receive it.
In the article “Hospice problems raise concerns on oversight,” Georgia Health News reporter Andy Miller points out the significant growth in the field and raises concerns of oversight. Yes, costs and access have increased significantly. However, a deeper understanding of what lies behind the numbers must be part of the discussion.
Nationwide, the number of patients served annually by hospice has grown from 700,000 in 2000 to more than 1.5 million. This growth reflects that more Americans are opting for compassionate, comprehensive, quality care at life’s end. Hospices are meeting the needs of those in their communities.
Back in 2000, for every person who received hospice care, there were two others who would have benefited from it but did not get it. Ten years ago, the majority of those served by hospice had some form of cancer, and their illnesses followed a fairly predictable path. Today, less than 40 percent of hospice patients have cancer, and hospice providers are serving more patients with complex illnesses, such as late-stage dementia, who have uncertain trajectories, making prognosis much more difficult.
A private residence remains the primary location of most hospice care in the U.S. However, hospices have been working diligently to reach people in need of care wherever they are. Hospice is available to people in nursing homes, assisted living facilities, hospitals and residential facilities. Research out of Brown University demonstrates that having hospice care in the nursing home not only benefits hospice patients but increases quality throughout the nursing home, an important factor during these times when quality is of increasing importance.
Medicare spending on hospice has risen to $12 billion annually, or 2 percent of Medicare’s budget. These are dollars well spent. Independent research out of Duke University has shown that for every Medicare beneficiary who utilizes hospice, Medicare saves about $2,300. In an atmosphere of reimbursement cuts, with average net margins of less than 3 percent (according to MedPAC statistics), the hospice community remains a fiscally responsible provider of cost-effective, quality health care.
The past decade has seen an increase in the number of hospices nationally. With growth, we have witnessed a handful of providers that have ignored compliance standards, or even commit fraud. However, the actions or experiences of a few should not be used to paint an image of the entire industry.
As in any sector of health care, cases of fraud can be found. Expecting hospice to be immune to these challenges is unrealistic. Yet the hospice community, led by the National Hospice and Palliative Care Organization, has acted quickly and decisively to respond to these issues, providing education, mentoring and resources to help hospice providers succeed in their mission and duty to deliver high-quality care to those in the last months of life.
As was reported by Georgia Health News, hospice leadership has repeatedly called for more consistent and timely oversight of providers. NHPCO continues to lead the field in supporting legislation introduced in the Senate mandating CMS surveys of hospice programs at least as frequently as every three years.
Well before health care reform, a voluntary Quality Partners program, with self-assessments and other resources and tools to assist providers with quality measures and performance improvement, was created by NHPCO.
In addition, NHPCO has consistently supported the “aggregate financial cap” that places a limit on the amount of Medicare payment for all Medicare beneficiaries served by a hospice in a year.
Recently, concerns over the growth of for-profit providers in the field have surfaced in the media. Hospice – which began as a volunteer-led, grass-roots movement in the United States in the late 1970s – has moved beyond the all-volunteer organization. Now the hospice community reflects the broader health care industry in the nation. NHPCO research shows that patients served by both for-profit and non-profit hospices receive high-quality care.
Attention has also turned to patients who have received long lengths of service. (NHPCO research shows that in 2009, 11.8 percent of patients remained under hospice care for longer than 180 days). However, MedPAC, Congress and CMS have ignored the other end of the spectrum, offering no solutions to the problems with short lengths of stay – problems that have not changed in a decade.
More than a third of patients cared for by hospices die in seven days or less. When a patient or family receives care for such a brief period, it is incredibly difficult for hospice providers to transform the experience of the patient and family from crisis care to compassionate care.
Every aspect of health care must be reviewed to ensure that taxpayer dollars are being optimized to ensure that people receive the best possible care. But we must ensure that in our efforts to cut costs, we do not unintentionally prevent patients and families from accessing the most comprehensive, cost-effective, patient-centered care – hospice. Individuals who are facing the end of life, and their family caregivers, deserve the best humankind has to offer – and that is hospice.
J. Donald Schumacher is the president and CEO of the National Hospice and Palliative Care Organization, the nation’s oldest and largest leadership organization representing hospice and palliative care providers and professionals.
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