The
Hospice e-News
What the Media Said about End-of-Life Care This Week
Week of June 6, 2006
…a service of
HOSPICE HAS EVOLVED FROM
In “The Business of Hospice Care” at Wharton’s Knowledge @ Wharton website, Wharton Professor John Kimberly says that hospice as a business has evolved from a non-profit mission to a healthcare business. The article cites Wharton faculty and industry analysts as saying that hospice will become an even more important part of healthcare than it has been heretofore. According to CDC figures, Medicare reimbursement for hospice care totaled $68.3 million in 1986. This year, says the article, that total will probably reach $9.5 billion and is expected to total $45.6 billion by 2030. Kimberly says that hospice’s growth is “hampered by physicians who are reluctant to recommend the service.”
Research shows, says the article, that hospice can reduce Medicare costs. According to Kimberly, “The largest portion of hospital expenses is incurred in the last few weeks of a person’s life. So one could argue that if it were possible to make relatively accurate judgments about when an illness is terminal, and if legitimate hospice services can be provided to the patient, cost savings would result.” When families are insistent upon prolonging life as long as possible, says the article, there exists a conflict between their wishes and any possible cost containment.
Over the next five years, CIBC World Markets, an investment bank, expects hospice spending to increase 9.1%. The elder population is growing and hospice is expanding to serve many more medical conditions other than cancer care. Geographically, hospice usage is uneven. In 10 states, more than 40% of persons over 65 who died were in hospice care, compared to only 20% in 13 others.
Eric T. Gommel, vice president of equity research at Stifel Nicholas, says that “Congress seems intent on keeping hospice well funded.” Gommel says that there are ways for hospices to make a profit in spite of Medicare mandates about services and payment rates. Gommel expects for-profits with “better access to funding and economies of scale” to effectively compete with local non-profits. Roseanne Berry, a founder of VistaCare, expects the industry to consolidate and expresses concerns about healthcare shortages.
Costs and costs-savings differ from illness to illness. A study published two years ago in the Journal of Pain and Symptom Management reported that hospice care usually reduces costs of caring for cancer patients but not necessarily for patients with COPD, congestive heart failure and dementia. Stephen Connor, NHPCO vice president, says that late entry into hospice is one of the reasons for the higher costs. “Hospice adds value by providing quality care and preventive medicine. If the patient is in hospice seven days or less, it’s too late to prevent that final hospitalization, and we become an add-on cost at that point.”
Mark Pauly, professor at Wharton, says, “Hospice might be most valuable for families who want extra assurance that doctors will not use heroic measures to prolong a patient’s life for only a short period of time.” Both he and Kimberly think that families often change their minds about what they want as death approaches. Death with dignity is attractive when one is feeling well, he says, but “when they are finally faced with death, people and their families change their minds and they try everything.”
J. Donald Schumacher, NHPCO president and CEO, says that hospitals are “increasingly adding pain management and other non-curative treatments to their business models.” “Some hospitals are developing innovative programs for palliative care which is pre-hospice for patients who are in need of symptom management, but are not quite ready for hospice care. There is a nice synergy developing between hospice and hospitals,” he says.
See knowledge.wharton.upenn.edu/
for the online article. Search for
hospice in the quick search box. (Knowledge @ Wharton Website, 5/31)
HOSPICES ADDRESS COSTS AND
BENEFITS OF OPEN ACCESS
Hospice professionals have been debating, says an article in Hospice Letter, whether open access policies have positive or negative impacts. Some fear such a policy will be a financial burden, says the article, while others report positive impacts. Some hospices have explicit open access policies, others have informal ones and some have no policy at all.
The goal of those hospices that have open access policies is the provision of “hospice care to anyone who seeks it, regardless of ability to pay or treatment options,” the article says. But one survey respondent wrote, “We have a modified open access policy/philosophy. We believe that many of the patients who receive palliative chemotherapy and radiation should be allowed but, as a small organization, just cannot afford it.”
Another respondent wrote, “So far, the financial benefits of open access, resulting from longer length of stay, seem to be mostly speculative. Articles in the hospice media often refer to a positive impact on census, without reporting the financial impact, the cost/benefits of paying more expensive treatments in return for more patient days. There is also the issue of economy of scale – how big does a hospice have to be to take on the risk?” (Hospice Letter, 6/2006)
NYT EXAMINES COMPLEX REGIONAL PAIN SYNDROME
Cynthia Toussaint, profiled in a recent article in The New York Times, lives with complex regional pain syndrome. Toussaint pulled a hamstring in a college dance class and spent the next 20 years in agony from complex regional pain syndrome (CRPS). Formerly known as reflex sympathetic dystrophy syndrome, the nerve disorder can cause the pain messages to be constantly sent to the brain from even a minor injury. For years, doctors considered the pain to be psychosomatic, but recent research has disproved that assumption. It is now believed that one of every 1,200 injuries may be complicated by CRPS.
Though the condition was first described during the Civil War, the article says that few doctors are familiar with it and that patients often visit 8-10 physicians before being diagnosed. In some patients, the pain stays in one place in the body, usually an extremity. In others, the whole body hurts, “making even a light touch or minor changes in temperature agonizing.”
CRPS outranks cancer pain as the most painful disease, but successful treatment is hard to come by. Sympathetic nerve blocks may reduce it and drugs, from acetaminophen to morphine and methadone, are used to treat it, but none of the drugs are FDA approved for the treatment of CRPS. Some physicians use electrical stimulators, but at least one physician says he no longer does because “they wear out and then they stop working.”
Dr. Robert J. Schwarzman, of
Toussaint and her partner, John Garrett, manage their website, For Grace, that increases awareness of CRPS (see www.forgrace.org). She is also campaigning for the California State Assembly, basing her platform on health issues. (The New York Times, 5/30)
PUBLIC POLICY NOTES
* Oklahoma Governor Brad Henry (D) has signed legislation that allows state residents “more specific options for refusing life-sustaining treatment.” A spokesperson for the Oklahoma Bar Association said that the older forms were still valid and legal, but that the new form has more options. Persons who signed the older form should complete a new one, which can be downloaded from www.okbar.org. (Journal Record, 5/25)
* Several states are filing suit against
drug companies that they accuse of improper marketing practices.
* A hearing was scheduled late last week
to determine whether Dallas Children’s Hospital can disconnect the
life-supports of ten-month-old Daniel Cullen.
Daniel, a premature baby with continuing breathing problems, pulled the
breathing tube out of his neck while living at home with his mother. Doctors contend that he suffered irreversible
brain damage. His mother successfully
obtained an injunction keeping the hospital from removing life support on May
21 as it had planned. (The
* A brief editorial on the nursing
shortage, published in The New York Times,
says, “The idea of the richest country in the world skimming the scant cream
off the health care staffs of poor countries is disturbing.” The
OTHER NOTES
* The
* Airlines are dropping bereavement fares as part of their cost-cutting strategies. While there has been some criticism of the moves, some of the airlines and even some travelers say they’re no longer needed – and they’re often more expensive than the last minute deals available on websites or through discount airlines. With the loss of the programs, travelers lose flexibility in travel plans, as the bereavement tickets often allowed change of date and time of tickets with no penalties. (The Wall Street Journal, 5/31)
* An article from The Philadelphia Inquirer says, “Although patients seldom know it,
many patient groups and drug companies maintain close, multimillion-dollar
relationships while disclosing limited or no details about the ties. At a time when people are making more of
their own health-care decisions, such coziness raises questions about the
impartiality of groups that patients trust for unbiased information.” An Eli Lilly & Co. executive charts the
growth strategy for the American Diabetes Association, the National Alliance on
Mental Illness “lobbies for treatment programs that also benefit its
drug-company donors” and Genzyme, a drug maker,
“supplies nearly all the revenue of the National Gaucher
Foundation.” (The
* William Colby, the lawyer who
represented Nancy Cruzan’s family, has written Unplugged: Reclaiming Our Right to
Die in America. In an interview with
The Kansas City Star, Colby says,
“The rapid advance of medical technology” has changed the equation of the past,
when seriously ill patients either improved, or died fairly quickly, and that
“most dying takes place today in institutions and usually as the result of some
decision.” (The
*
* An article in
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and liability insurance for hospices and home healthcare agencies through their
Hospice and Community Care Insurance Services division. Ask your insurance agent to visit their
website at www.hccis.com.