Medicare Takes a Pass on Expanding Hospice Care—For Now

Many Medicare recipients delay getting hospice services because they must agree to cease curative treatments such as chemotherapy. So by the time they do enter hospice, their condition is much more dire, and many often have mere days to live. Some never make it to hospice at all, and spend their final days in a hospital intensive care unit.

So three years ago, Congress directed Medicare to test an expanded hospice program. It would enable beneficiaries to continue potentially lifesaving treatments, possibly to improve their quality of life, while saving money by avoiding expensive hospital care. But, as told in a story by Kaiser Health News and PoliticoPro, the program has yet to begin.

The Affordable Care Act (“Obamacare”) required Medicare to subsidize hospice care while also paying for treatment-for children. It’s called concurrent care, and most states have such a program for low-income residents. The ACA also said 15 sites should be chosen to test concurrent care for Medicare patients, which covers disabled people and those older than 65.

What’s taking so long? Dr. Randall Krakauer, an Aetna executive instrumental in establishing its concurrent care program for private coverage, told KHN/PP that Medicare “is missing an opportunity. Our own experience is when you do liberalize the hospice benefit, it does not cost you extra and it may actually cost you less.”

Krakauer said Aetna asked for permission to expand concurrent care to the 448,000 elderly people enrolled in its Medicare Advantage plan. Aetna even said it would cover any extra costs, but Medicare never responded.

Officials at the Centers for Medicare & Medicaid Innovation, which is responsible for managing the expanded program, declined to discuss the delay with the news organizations, issuing only a news release expressing its commitment to “allow beneficiaries to receive both palliative and curative care at the same time … ”

Apparently, CMS has commitment issues.

According to KHN/PP, hospice is one of the fastest growing parts of Medicare. In 2011, 1.2 million Medicare beneficiaries used the benefit, double the number who did so only a decade earlier. Medicare spent $13.8 billion on hospice; the average per-patient cost was $11,342.

Palliative care, as opposed to curative care, focuses on a patient’s comfort, not on prolonging life. Hospice advocates say that palliative care has the dual virtue of being more humane and less expensive. A study published in Health Affairs, “Hospice Enrollment Saves Money For Medicare And Improves Care Quality Across A Number Of Different Lengths-Of-Stay,” found that patients who were enrolled in hospice at least three months before they died cost Medicare less than those who never used the benefit.

The average cost to Medicare of hospice patients enrolled between 53 and 105 days was $22,083 compared with $24,644 for patients who never enrolled.

You can’t know for sure if hospice patients who get both palliative and curative care would cost less until you establish the program. (The ACA forbids Medicare to spend more money on the patients in the demonstration project than it otherwise would have.) But Aetna told KHN/PP that it saved an estimate 22% on patients younger than 65 in its concurrent program.

According to the news organizations, some health policy experts ascribe the delay in implementing the program to … politics. End-of-life care is a sensitive subject-remember how some ignorant demagogues liked to invoke the scary term “death panels” during the robust debate before passage of the ACA?

To learn more about palliative and hospice care, and to locate hospice services near you, visit the website of the National Hospice and Palliative Care Association.

To learn about health care power of attorney and living wills, see our newsletter “Talking to Your Doctor When You Can’t Speak.”

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