At Home in Hospice
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Recent research has shown wide variation in the services and profit margins of the two business models. One 2005 study in the Journal of Palliative Medicine found that large hospices owned by publicly traded companies generated profit margins nine times higher than those of large nonprofits and three times higher than privately owned for-profit groups of similar size. In another study of hospice ownership, Mount Sinai’s Carlson found that for-profits provided a narrower range of services to patients and their families, particularly in more discretionary areas that are not as closely regulated by Medicare.
The rapid expansion of for-profit hospices in particular has also attracted more government scrutiny. In response, the NHPCO has worked with hospices to develop quality measurements tied to Medicare’s revision of hospice conditions of participation (the federal rules governing hospice providers) that are scheduled to be released within the year. Proponents say that releasing data on hospice quality to the public will give consumers a better idea of what they can expect from providers. But others consider such measures crude yardsticks, particularly when they involve such “noncore” services as social and spiritual support.
Meanwhile, in a report to Congress last year, the Medicare Payment Advisory Commission, the government entity that serves as Medicare’s watchdog, released a report suggesting reimbursement payments be adjusted to reflect such factors as diagnosis and length of stay. It also suggested that Medicare payouts be staggered, with larger amounts paid for the beginning and end of hospice stays, which are most costly for providers. The goal is to create a more accurate payment system, though overall payouts to hospices probably would not rise.
Thanks to medical advances that have reduced the incidence of such swift killers as heart attacks and strokes, people today are dying more slowly than ever, while deaths from gradual illnesses, such as Alzheimer’s and cancer, are increasing. Those trends, along with the aging of the baby boom generation, are likely to mean mushrooming numbers of hospice candidates. But not everyone is convinced that hospice is the only answer.
A new medical specialty called palliative care is one alternative. Some 30% of hospitals have launched palliative care programs in recent years, using a team approach to provide curative treatment while also controlling pain and attending to other quality-of-life issues. Such care avoids hospice’s unfortunate requirement that patients accept death, says J. Andrew Billings, director of the Palliative Care Service at the Massachusetts General Hospital.
“Hospice and palliative care largely share the same philosophy, though the notion of palliative care is that a patient can get all of the things hospice provides—pain and symptom management, psychological support, a respect for wishes and values, help at home—but also can get well and extend his or her life,” says Billings.
Ultimately, though, death will come, and whatever their differences, both palliative care units and hospices must confront the same increasingly complex end-of-life issues. “As a society we’ve just started tackling the questions of advancing medical technology and how we decide when to use it and when not to use it,” says William Colby, a lawyer and the author of Unplugged: Reclaiming Our Right to Die in America.
Those questions include how to handle patients who have been admitted to hospice or palliative care units without do-not-resuscitate orders or advance directives about halting aggressive treatment, says Robert Miller, a minister and ethics expert at VITAS. Sometimes, families of patients may push to prolong the lives of patients who can no longer make their own decisions, even when those patients had asked not to undergo such measures as feeding tubes or ventilators.
As deaths surge in the decades to come, the entire U.S. health care system will increasingly face these concerns, but they’re already front and center at the U.S. Department of Veterans Affairs. This year alone, more military veterans will die than were lost during all of World War II, and they already account for one in four of the nation’s deaths. To provide flexibility for patients, nearly all Veterans Administration facilities offer palliative care that’s coordinated with hospice care, either within the hospital or at home through community hospice organizations.
That has helped Charles Bennett, 63, live more comfortably with terminal lung cancer, enabling him to move from the inpatient hospice at the Birmingham VA hospital to his rural home, where his care is monitored by VA physicians. Daily doses of morphine are keeping him pain-free for now, but Bennett, a retired salesman, has made it clear that there will be a time when all treatment should end. He doesn’t want to be put on a ventilator or resuscitated when that moment arrives, and all of the doctors and nurses involved in his care will abide by those wishes. “With hospice I can just relax during the time I have left,” Bennett says. “I know everyone will do what they’re supposed to do.”
