The Hospice e-News
What the Media Said about End-of-Life Care This Week
Week of June 20, 2006
…a service of
MEDPAC’S
REPORT TO CONGRESS ADDRESSES HOSPICE
The Medicare Payment
Advisory Commission (MedPAC) report, given to
Congress in June, includes a chapter on hospice. The 19-page chapter, titled “Medicare's
hospice benefit: Recent trends and
consideration of payment system refinements,” addresses the growth and change
in the Medicare hospice benefit, offers a consideration of payment system
refinements and identifies directions for further investigation of the Medicare
hospice patient.
In 2004,
Medicare spent $6.7 billion and the “CMS Office of the Actuary estimates that
the Medicare program will spend $9.8 billion on hospice care for beneficiaries
in 2006.” Spending for hospice care is
estimated to increase from 2004-2015 by “an average rate of 9 percent per
year,” a rate that exceeds expected spending growth for “hospital, physicians,
skilled nursing facility, and home health services.”
Hospice
data are inadequate, says the report, to allow accuracy in interpretation. “Medicare
data do not permit a detailed assessment of the relationship between
patient-level characteristics and service use and cost. For example, the claim does not indicate
whether a beneficiary lives in the community alone or with a caregiver or lives
in a nursing home—circumstances that might affect service use or agencies’
cost.”
The report
addresses hospice margins, noting again that data are limited, and says that
margins “vary by facility size and other characteristics.” The MedPAC reports
cites a GAO estimate that says, “Smaller hospices had, on average, higher per
diem costs than large or medium hospices for each of the payment categories.” A 2005 study said, “The median margin for
large for-profit agencies was 18 percent, but the median for large nonprofits
was 2 percent.” But the margins were
calculated on all payments received by the hospice and may not adequately
reflect the Medicare margins. Total
margins for 2004 were reported as an average of 11-19% by an NHPCO study. The report clarifies, however, that NHPCO
reports that when fundraising dollars are excluded from the report, the average
agency margin is 2%. Overall, the report
notes, the “data are merely suggestive of the magnitude and variability of the
current relationship between costs and payments across the industry.”
Hospice
utilization is on the rise, with the rate of hospice use growing from 22% of
decedents in 2000 to 31% in 2004.
Decedents in managed care plans have a higher rate of utilization than
those in fee-for-service plans. Overall,
the highest rate of hospice users continues to be among white Medicare
beneficiaries. But, says the report, the
increased utilization of hospice by all racial and age groups “suggests
improved awareness and appreciation of the benefit by physicians, hospitals,
patients, and their families.”
The number
of Medicare-certified hospices continues to rise, growing by 26% from 2001 to
2005, and the provider types of hospices have changed. In the 1980-82 demonstration, says the
report, 42% of hospices were hospital based, 31% freestanding, and 27% home
health based. In 2005, 57% of hospices
were freestanding and 46% were for-profit, up from 31% in 2001. All of these changes, says the report, “suggest that the hospice payment system should be
re-evaluated.”
The report
notes that it will be difficult to assess the accuracy of the current payment
system and gives significant coverage of the data limitations. Results from a Rand study, on one large
chain’s services and costs, are used to address how well the per diem system
works with the variance in hospice patient’s uses of resources, whether
case-mix adjusters should be used and if the first and last days in hospice are
more intensive.
The report
includes numerous tables and charts of hospice information and data. The authors call for additional data
gathering that will help more fully assess costs and quality of care. “The results of these analyses inform payment
update recommendations that are intended to maintain Medicare beneficiaries’
access to high-quality care while getting the best value for taxpayers’ and
beneficiaries’ resources.” The full
report is available online at http://www.medpac.gov/. (Report
to the Congress: Increasing the Value of
Medicare, 6/2006)
HOSPICE AND PALLIATIVE CARE NOTES
* “Hospice patients’ views on research in palliative
care” is an article in the Internal
Medicine Journal. The study was
conducted to explore whether terminally ill patients share the concerns that
researches often have about using them in research studies. Interviews revealed that patients want to
participate in research for a variety of reasons. Altruism, a sense of value and maintaining
autonomy were among these reasons. “They
rejected the view that consent might be non-autonomous and put forward
consistent views about what they considered relevant to consent.” The study concludes that patients do “not
share the concerns of ethicists about the difficulties and hazards of research
with the terminally ill.” (Internal Medicine Journal, 2006;36(7):406)
* “Sudden
Traumatic Death in Children” appears in JAMA and highlights a case that
demonstrates “the importance of interdisciplinary communication, the vital role
of social workers and other psychosocial providers with expertise in working
with families, and the critical significance of mutual care and support for the
clinicians who accompany families through these tragic events.” (JAMA, 2006;295:2646-2654)
POLICY
NOTES
* Saying
that not enough is being done to help patients locate information on advance
directives, the AMA voted at its recent meeting to do more to promote advance
care planning. “The tragic case of Terri
Schiavo made many Americans acutely aware of the
risks associated with not clearly communicating end-of-life decisions,” said
AMA board member Robert Wah, MD. More needs to be done to help people locate
the documents and start the process, and AMA says it will work with “Medicare,
health insurers and state Departments of Motor Vehicles to distribute
information about living wills.” The AMA
decision drew praise from NHPCO. AMA
voted, according to PR Newswire, “to
increase patient and physician education surrounding advance directives.” Caring Connections, a program of
NHPCO, has a major initiative in advance care planning. (LifeNews.com,
6/13; PR Newsire,
6/14)
* The Citizen's Health Care Working Group
has published a 12-page report that is “thought to be the first wide-ranging
effort sponsored by the government to poll average citizens on health care
policy.” After some 35 meetings held
across the nation and several Internet polls, the 15-member panel, created by
Congress, has suggested six initial recommendations. Recommendation number six is to “restructure
end-of-life services to increase access.”
The group says that citizens should “clearly understand their options
and have their choices carried out accordingly.
Communication among providers, patients and their families is vital. Funding, at the community level, should be
available to help individuals and families gain access to care.” Congress will hold hearings on the report and
that will likely happen next year. The
entire report of interim recommendation is available online at http://www.citizenshealthcare.gov/. (
PAIN NOTES
* The Pain
& Policy Studies Group (PPSG) has received
funding for its US pain policy evaluation program from the American Cancer
Society, the Susan G. Komen Breast Cancer Foundation
and the Lance Armstrong Foundation. The
funding provides a three-year grant that will allow the PPSG to “evaluate
federal and state laws, regulations and agency guidelines that can impact
patient access to effective pain relief.
PPSG will prepare state policy profiles for the next
three years, as well as report cards that grade states’ policies and compare
them to the 2000 and 2003 grades.
Release of the 2006 reports is anticipated in September, which is Pain
Awareness Month.” For more information,
go to http://www.medsch.wispainpolicyc.edu//news/funding.htm. (PPSG
website)
* A study from the
* “If you
are old or a woman or a person of color, and you’re in pain, you probably won’t
be surprised then if you don’t get the same medical attention as a
pain-suffering, middle-age White man, who ‘receives what many consider the gold
standard of treatment,’ physician Carmen Green says.” So begins an article in The Arizona Republic that shares some of the dilemmas of pain
management and describes variances in the quality of pain management. (The
* Those who are less able to communicate about their pain
are more likely to receive insufficient pain management. The American Society for Pain Management Nursing
published a position paper that “describes the severity of this issue, defines
populations at risk and offers strategies, tools and resources for appropriate
pain assessment.” The paper, “Pain Assessment in the Non-verbal Patient,” is
online at
http://www.aspmn.org/Organization/documents/PainAssessmentintheNon-VerbalPatientFINAL.pdf. (American
Society for Pain Management Nursing)
* More than half of about 20 million who
responded to a recent survey, conducted by the American Society of
Health-System Pharmacists, believe that little can be done to deal with the
chronic pain of medical conditions such as cancer or arthritis. The results, says an article from Cox News Service, mirrors “attitudes that
have continued relentlessly,” despite numerous educational and public relations
campaign. The article calls on citizens,
physicians and medical schools to work to improve the practice of pain management
and to look for all ways to relieve pain and suffering. “Those who suffer,” says the article “must be
aware of their right to relief.” (Cox News Service, 6/13)
NURSING SHORTAGE NOTES
*
* A study funded by the Robert Wood Johnson Foundation
says that more nurses will stay on the job as they age if they “have flexible schedules
and ergonomic workplaces, besides the incentives of good pay and attractive
retirement plans.” (Modern Healthcare’s Daily Dose, 6/15)
AGING NOTES
* An article in The
New York Times explores the taboo of nursing homes that is being faced by
Muslims in the
* The state of
OTHER NOTES
* There is an Internet petition calling for the early
release from prison for Jack Kevorkian.
Kevorkian is up for parole the middle of 2007, but his friends fear that
he may not live that long. According to
an article in
* An article in The
Miami Herald describes numerous ways that memorials to loved ones are
changing. T-shirts and hats are “almost endemic
to black and Hispanic communities.”
Memorials placed on the Internet or on roadside markers cross ethnic
lines. One young person’s photo will be
spray-painted on the hood of the car he loved and his face was tattooed on the
arm of his cousin. At legacy.com, people
can “read, watch or listen to tributes to thousands of people…” (
* Counterfeiting of pharmaceuticals is a “$30 billion global
problem for the drug industry, involving 8 to 10 percent of drugs sold….” In December, says the FDA, “long-delayed
federal rules requiring most wholesalers to be able to track prescription drugs
from factory floor to pharmacy door will finally take effect….” Regulations will include the use of bar codes,
written documents and radio tags. (New York Times, 6/10)
* Senate Finance Committee Chair Charles Grassley,
(R-Iowa), has asked the IRS to “step up enforcement of laws governing tax-exempt
organizations, including hospitals.”
Grassley expressed concern about how non-profit hospitals “calculate the
amount of free care they provide to uninsured patients and other benefits to
the community, as well as the big paychecks their executives receive.” (Plain
Dealer, 6/9)
Thanks
to Jonathon Krutz for contributions.
Glatfelter Insurance Group is the national sponsor of Hospice News
Network for 2006. Glatfelter Insurance
Group provides property 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.