We spend more money on healthcare in the last months of life than at any other time. It’s when we’re sickest and most in need of medicine, doctors and intensive care.
According to estimates, nearly 30 percent of Medicare’s annual $327 billion budget goes to caring for patients in their final year of life.
But despite the whopping price tag, palliative care has received relatively little attention as the battle for health care reform has roared on, leaving those in the business on the sidelines in frustration.
H.R. 3962, the Affordable Health Care for America Act, which was passed by the House earlier this month, includes a cost-saving provision that intends to reduce hospice reimbursements by almost 12 percent by 2019, according to Dr. Porter Storey, executive vice president of the American Academy of Hospice and Palliative Medicine, the professional organization for specialists in the field. With already-planned cuts, that number could surge to 14 percent.
Storey and other advocates say that, if passed, the cuts would deliver a crippling blow to the quality of hospice care.
“The hospice community simply cannot endure the productivity adjustments proposed,” the National Hospice and Palliative Care Organization wrote in an open letter to legislators in response to the America’s Healthy Future Act (or the “Baucus Bill,” which was passed by the Senate Finance Committee shortly before the bill in the House).
At the moment, hospice care profit margins nationwide stand at just more than 3 percent, according to a June 2008 MedPAC report cited by the letter.
But the margins vary widely across the board, explained William Dombi, vice president for law at the National Association for Home Care & Hospice, based in Washington, D.C. While some providers are raking in 30 percent profits, there are also numerous non-profits and smaller facilities, especially in rural areas, that make significantly less. Many operate at a loss or rely on donations to provide care.
“With these cuts, a lot of these [smaller, non-profit] hospices will be closing their doors,” said Dan Chin, director of public affairs for HospiceCare Inc., a non-profit hospice network.
Even providers who are able to keep their doors open will have to be more selective in the patients they choose. They are also likely to cut staff, meaning lower doctor- and nurse-to-patient ratios and less time spent between patients and doctors.
Yet hospices have been shown to provide higher quality—and cheaper—care than the alternative. The letter cites one study by the Robert Wood Johnson Foundation that found that patients who receive hospice care save Medicare, on average, $2,300 each. Another found savings of $3,192 during the last months of life. Patients who receive hospice care don’t end up in emergency rooms. They don’t see numerous doctors and don’t double up on medications they don’t need.
The foundation study estimated that, in total, hospice care saves the program more than $2 billion a year.
A 2007 study published in Journal of Pain and Symptom Management reported that hospice patients live nearly a month longer than those in non-hospice care—a significant increase, considering life expectancy at the time of admission is six month or less.
Most of the reductions to end-of-life-care outlined in the proposed bills will come from slashing Medicare, which funds hospice providers on a per-day basis: the House bill calls for a $56.8 billion cut, and the Senate Finance Committee a $43.2 billion cut, according to Dombi.
If the cuts are approved, he said, “There will be serious access-to-care problems. This is like removing one of the legs of a stable health delivery system.”
New York would be particularly hard-hit by the cuts, Dombi said. New York State has been the leader in home and community-based care, and profit margins for home health care agencies here are generally lower than the rest of the nation, he said, meaning there’s less room to cut.
But the bills are not all bad. The Senate version does expand home and community-based services and shifts long-term-care spending to home-care rather than nursing homes, which patients overwhelmingly prefer.
One Senate proposal will discount the incomes of the spouses of Medicaid patients who are treated at home in the same way as those who are treated in a nursing home, making more people eligible, Dombi said.
But advocates say it just isn’t enough.
“I’m very disappointed,” Storey said of Congress’s priorities. The changes, he said, “will force a lot of people who would rather have comfort care at home to go back to emergency rooms and spend more time in the hospital.”
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