Hospice in Medicare: a Victim of Success?

A recent article in the Wall Street Journal (subscription required) reports that Medicare is paying more than expected for hospice care.  The apparent reason:  hospice is being provided to people who are not close to death.

The initial idea of hospice was to provide palliative care for people with 6 months or less to live.  Leave aside, for the moment, that making such a prognosis is an imprecise practice, or that good hospice care might actually extend life by a little bit.  Hospice care is intended to be “comfort-oriented” and a lot less expensive than intense, invasive, active treatment that can include toxic drugs and long stays in the hospital.  A common assumption, often unspoken, is that hospice is or should be limited to people with advanced cancer, although there is no reason why that would have to be so.

Palliative care is improving, and as it does, is becoming more widely adopted as standard of care for people with life-threatening illness.  Oncologists are encouraged to start palliative care early in their treatment of all patients with advanced cancer.  Of course, that doesn’t mean hospice as such.  But it does blur a line.

And so, about a third of Medicare payments to some hospices are for people who receive care for over a year.  Some of this appears to be attributable to successful palliation.  But much can be traced to the fact that some people receiving hospice care have other long-term conditions like dementia, with more indefinite survival prognoses than a cancer patient who has exhausted all known effective treatment options.

In the end, the challenge seems to be a conflation of hospice and long-term care, and with it, a serious underbudgeting for hospice within Medicare.  Oops.

The WSJ article reads like an expose.  But my reaction was not that mischief was afoot, but rather that this is yet another way in which the aging of our people puts stress on Medicare or any other arrangement designed to share the costs of caring for the infirm.  Long-term care insurance companies have stopped writing policies, greatly limited their scope, or exited the business altogether. 

This is a problem that may drain a lot of coffers over the next generation, but I wouldn’t blame it on hospice or on the practice of palliative medicine.

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