CHRISTOPHER M. HUGHES

The gift of hospice

New rules raise new questions about end-of-life care

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There has been a lot of talk lately about hospice — specifically about tightening regulations that govern eligibility for this specialized end-of-life care and for how long patients can access it.

Recent articles have focused on the dilemma in which some families find themselves: feeling a loved one in hospice could benefit from continued services but being told by their health insurer that their loved one is no longer eligible. The question is asked: Are patients being admitted to hospice too soon?

At the same time, many health-care providers encourage advance-care planning so patients may benefit from the full complement of hospice services sooner rather than later. Why? Let’s examine the core intent of hospice and its advantages.

The Hospice Medicare Benefit, which was established in 1983, pays for care and treatment that is reasonable and necessary for easing the course of a terminal illness but that is not curative in nature. To be eligible for Medicare’s hospice benefit, a patient must be entitled to Medicare Part A and be certified by two physicians to have a life expectancy of six months or less if the illness were to run its expected course.

But living longer than six months does not mean the patient loses the benefit. After the initial Medicare certification period, each hospice patient may be re-evaluated by a hospice physician — and his or her own attending physician — and continue receiving hospice care if his or her condition is deemed by both to still be declining.

Hospice offers a team approach that is dedicated to aligning care with the patient’s wishes. It is the original “patient-centered care” we hear so much about now.

A hospice team may include doctors, nurses, health aides, social workers, spiritual care specialists, volunteers and bereavement counselors — all providing care at a hospice center or wherever the patient calls home. The hospice benefit also covers medical devices, supplies and medications that manage pain and symptoms.

Studies have shown that hospice care improves quality of life, is more cost effective than lengthy hospital stays and, in some cases, extends life expectancy.

So, what’s the issue?

Medicare is monitoring hospice more closely than ever because some providers throughout the country are alleged to be keeping patients in their care much longer than they should in an effort to boost their bottom line. That may happen in extremely rare cases, but the goal is to provide sufficient comfort care to improve patients’ quality of life, while also offering education and support to caregivers and loved ones.

There are those who continue to pose the question: If hospice is meant to be end-of-life care, why do some patients get “discharged?”

The answer is two-fold. One reason is ever-changing patients and illnesses.

A growing percentage of hospice patients have illnesses with outcomes that are hard to predict. In the past, cancer was the dominant hospice diagnosis. Now, the portion of hospice patients with cancer — one of the more-predictable diseases — has declined. Today, non-cancer diagnoses (such as dementia or heart disease) account for more than 63 percent of hospice admissions, according to the National Hospice and Palliative Care Organization.

The other reason for discharge is simply that reputable hospice organizations are paying close attention to the new rules. Most hospices are more careful than ever about the patients they admit and the patients they keep in their care.

To see a patient improve or stabilize to the point that she or he does not need hospice is a good thing. In fact, hospice providers embrace those rare opportunities to share such good news with families because it means their loved one has improved enough to no longer be eligible for hospice care.

The Affordable Care Act requires more stringent documentation of hospice outcomes, meaning we providers will be reimbursed based on our results, good or bad. In light of these changes, patients and caregivers ultimately will have higher-quality hospice providers from which to choose.

Recent high-profile end-of-life cases in the media have highlighted the important need for all of us — no matter our age — to document our care wishes in writing and share our thoughts in conversations with loved ones. After all, this is one of life’s most meaningful decisions.

So, take time to talk with your loved ones about your health care wishes, and theirs. Complete an advance directive to ensure your wishes are honored. Don’t allow those you love to have to make hasty decisions about your care when they are in crisis mode. Sharing your wishes, or learning those of others, is a priceless gift.

Christopher M. Hughes is co-chief medical officer at Family Hospice and Palliative Care, a nonprofit hospice provider in Western Pennsylvania.


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