Role Of Hospices
Ongoing public education about the roles of hospices helps to increase our awareness. There have been many programs on television, which have increased public attention to the needs of the dying and the bereaved. Numerous books, magazine articles and public lectures have also helped to make people more sensitive to the needs of the fatally ill. For the elderly and terminally ill there are a variety of agencies that work together with the goal of giving humane and expert care, and meeting the patients’ personal needs of comfort and support. These organizations include home care agencies, some health maintenance organizations, insurance companies and hospital divisions-for example, Veteran Affairs Medical Centers that are increasingly offering
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hospice services to eligible veterans. When hospices first began in the early 1970’s, the services were free of charge. Today, Medicare is often heavily used resource for financing hospice care. The development of hospices, the criteria used to determine hospice eligibility, the financing of hospice care and the impact and future of hospices are a few of the areas of key concern.
As hospices have become more successful at servicing those who are dying they have encountered more people who do not fit the requirements of this model. Many people are willing to discontinue seeking curative treatment even when the chances for effective treatment are minimal. The MHB eligibility is based on a belief that we can accurately predict six month mortality in most cases. Unfortunately we are not able toaccurately predict death within six months for most individual patients. Thus there are many people who will not qualify for the MHB In addition for anyone to make use of any kind of end-of-life program there must be an endstage to the disease condition. For a significant number of people who die there is no endstage; there is a sudden decline and death. (3)
When people who are suddenly disabled or near the end of life must enter a caring environment, whether in their home, a relative’s home, nursing home, or hospital they are often subjected to something called an assessment.
It is usually defined as a process that determines which problems are most prominent; it may be formal or informal and may be completed by relatives or professionals. From this assessment, a plan of care is developed to address and alleviate those problems. (1) When the dying accept hospice care they give up curative treatment. Instead hospice helps them to live out their final days alert and pain free. Early hospices represented a revolt against traditional medicine, which is seen as failing the terminally ill by giving them futile, but aggressive treatment. If someone was dying, a hospice volunteer went to the person’s home to do whatever is need, from emptying catheters to providing companionship. When hospices started in the mid-1970, no one was billed for these services. Funding came from charitable contributions. The hospice of the Florida Suncoast was started in 1975 by volunteers, who worked from a one-bedroom house with donated wheelchairs and walkers stacked in a bathtub.
In 1983 Medicare began to reimburse for hospice care, allowing hospices to serve far more people. Medicare fundsfueled a fourfold increase in patients served, from around 100,000 in 1983 to nearly 400,000 today. The Medicaid reimbursement enabled hospices to offer more sophisticated care that included skilled nursing and physical therapy. And it seemed like a goodbet for taxpayers. For every dollar spent on hospice patients in the last year of life, Medicare saves 1.52. But the savings are less certain after six months of
care.
Medicare involvement steered hospice away from its roots as a movement that relied primarily on volunteers. Today only 30 percent of hospices are independent community organizations, and most are division of hospitals, home care agencies, or regional hospice chains. The availability of Medicare funding led to the rise of for-profit hospices, which now make up 15 percent of the industry. And hospice care is one of the fastest growing medical expenditures. Medicare now pays for two-thirds of all hospice care, a total of nearly $2 billion a year. (2).
The current financing model of hospice care is based on the Medicare Hospice Benefit (MHB). Eligibility requirements for the MHB have tended to limit those who can be served by a hospice program. Most importantly patients must be certified as having six months or less to live if the disease runsits normal course and the patient must be willing to forgo attempts to curative treatment.
As hospices have become more successful at servicing those who are dying they have encountered more people who do not fit the requirements of this model. Many people are willing to discontinue seeking curative treatment even when the chances for effective treatment are minimal. The MHB eligibility is based on a belief that we can accurately predict six month mortality in most cases. Unfortunately we are not able to accurately predict death within six months for most individual patients. Thus there are many people who will not qualify for the MHB In addition for anyone to make use of any kind of end-of-life program there must be an end stage to the disease condition. For a significant number of people who die there is no end stage; there is a sudden decline and death.
(3)The National Hospice Organization (NHO) has drafted disease specific guidelines for determining prognosis. Various chronic diseases, such as chronic obstructive pulmonary diseases (COPD), congestive heart failure (CHF) and end-stage liver disease (ESLD), have such unpredictability that it is difficult to anticipate when death will occur in patients with these illnesses.
Investigators for the Study to Understand Prognosis’s and Preferences for Outcomes and Risks of Treatments (SUPPORT) tested the ability of currently used hospice criteria to identify patients whose prognosis for survival is less than six months. Adult patients with various chronic, non-cancer illnesses, specifically COPD, CHF and ESLD, were included unless they died or were discharged within 48 hours of enrollment. Of the 9,105 patients in SUPPORT, 2,954 were diagnosed with one of the illnesses in question. Of those, 2,607 survived hospitalization and were, therefore, potential hospice care candidates, but only 2 percent were actually discharged to a hospice service. One quarter of the potential hospice care candidates died within six months of discharge. When the broad inclusion criteria were used, 70 percent of the 923 patients identified as meeting criteria lived longer than six months, and the narrow criteria identified 19 patients referred to hospice care had a median survival of 23 days (versus 842 days for patients not referred to a hospice) The authors concluded that using the most restrictive criteria would successfully exclude patients who lived longer than six months (false-positive rate: 5.1 percent) but would also exclude almost all patients (false-negative rate: 99 percent) who would be eligible for and most likely benefit from hospice care. It remains difficult to predict a life expectancy of less than six months in gravely ill patients. Further study is needed to determine other ways to identify patients whose prognosis is poor and who would meet eligibility criteria. (4)
Medicare hospice benefit is a per diem payment that varies by region. The daily payment must cover all hospice expenditures for that patient, including medications used to treat the terminal illness, hourly pay for the nurses, and other professionals, supplies, and rental of medical equipment. The Medicare hospice per diem was cut back substantially under the Balanced Budget Act of 1997, and although some of the further scheduled cutbacks have been postponed, many of the hospice organizations are feeling the financial pinch.
Medicaid patients may also qualify for hospice benefits in some situations, and approximately 80% of employees in medium and large businesses also have hospice coverage under their health insurance plan. Most private insurance includes a hospice benefit, and 82% of managed care plans offer hospice services. When none of these sources of payment is available, many hospice organizations will provide services without charge or on a sliding scale, using funds raised through charitable contributions.(5).
Often when we consider the patient population in hospices many may believe that it consists of the terminally ill and elderly. While this is somewhat current statistics indicate that hospice patients are almost entirely white and more likely to be male.African Americans, Hispanics and patients who are uninsured or homeless are far less likely to be included. In America, you have a greater chance of dying in pain if you don’t speak English and if you are black, Hispanic, poor elderly, or a woman.
Constant shifts in the structure of the health care industry impinge on hospice, as they have on all sectors. Hospice organizations are still suffering from Medicare cutbacks imposed by the Balanced Budget Act, and while recent revisions have reduced the rate at which Medicare payments have been cut, reimbursement remains stagnant at a time when the costs of drugs and supplies are rising and hospice organizations face pressure to raise nursing salaries and benefits. Uncertainties about the future of Medicare also weigh heavily on hospice organizations. Cutbacks in private insurance coverage, especially coverage for family members, also impinge on hospice finances and make caring for patients who are not eligible for Medicare increasingly difficult. In the long term, the survival of the hospice depends on integrating stable, adequate financing for hospice coverage into whatever system of health care financing emerges from the present crisis.
Hospices have been a beacon shedding light on the issues and concerns of the dying patients and families. Yet there are many challenges for hospices some of the dilemmas:
Many physicians are reluctant to refer to hospice or make referrals too late in the dying process. Better physician training and continuing education can help to solve this problem. Secondly, Acceptance of palliative care can pave the way for hospice although specialized palliative care services based in tertiary care centers may conflict with the holistic philosophy of hospice. A realignment of these two approaches need to be sought. Thirdly, most hospice organizations are operating on a thin financial margin, squeezed by rising costs on one side and frozen Medicare reimbursements on the other. Federal budgetary surpluses may hold the answer. And finally in an ideal future, hospice concepts would be expanded outward from care of terminally ill patients to form a seamless web of caring for the elderly, the severely disabled, and the chronically ill. (7).
hospice services to eligible veterans. When hospices first began in the early 1970’s, the services were free of charge. Today, Medicare is often heavily used resource for financing hospice care. The development of hospices, the criteria used to determine hospice eligibility, the financing of hospice care and the impact and future of hospices are a few of the areas of key concern.
As hospices have become more successful at servicing those who are dying they have encountered more people who do not fit the requirements of this model. Many people are willing to discontinue seeking curative treatment even when the chances for effective treatment are minimal. The MHB eligibility is based on a belief that we can accurately predict six month mortality in most cases. Unfortunately we are not able toaccurately predict death within six months for most individual patients. Thus there are many people who will not qualify for the MHB In addition for anyone to make use of any kind of end-of-life program there must be an endstage to the disease condition. For a significant number of people who die there is no endstage; there is a sudden decline and death. (3)
When people who are suddenly disabled or near the end of life must enter a caring environment, whether in their home, a relative’s home, nursing home, or hospital they are often subjected to something called an assessment.
It is usually defined as a process that determines which problems are most prominent; it may be formal or informal and may be completed by relatives or professionals. From this assessment, a plan of care is developed to address and alleviate those problems. (1) When the dying accept hospice care they give up curative treatment. Instead hospice helps them to live out their final days alert and pain free. Early hospices represented a revolt against traditional medicine, which is seen as failing the terminally ill by giving them futile, but aggressive treatment. If someone was dying, a hospice volunteer went to the person’s home to do whatever is need, from emptying catheters to providing companionship. When hospices started in the mid-1970, no one was billed for these services. Funding came from charitable contributions. The hospice of the Florida Suncoast was started in 1975 by volunteers, who worked from a one-bedroom house with donated wheelchairs and walkers stacked in a bathtub.
In 1983 Medicare began to reimburse for hospice care, allowing hospices to serve far more people. Medicare fundsfueled a fourfold increase in patients served, from around 100,000 in 1983 to nearly 400,000 today. The Medicaid reimbursement enabled hospices to offer more sophisticated care that included skilled nursing and physical therapy. And it seemed like a goodbet for taxpayers. For every dollar spent on hospice patients in the last year of life, Medicare saves 1.52. But the savings are less certain after six months of
care.
Medicare involvement steered hospice away from its roots as a movement that relied primarily on volunteers. Today only 30 percent of hospices are independent community organizations, and most are division of hospitals, home care agencies, or regional hospice chains. The availability of Medicare funding led to the rise of for-profit hospices, which now make up 15 percent of the industry. And hospice care is one of the fastest growing medical expenditures. Medicare now pays for two-thirds of all hospice care, a total of nearly $2 billion a year. (2).
The current financing model of hospice care is based on the Medicare Hospice Benefit (MHB). Eligibility requirements for the MHB have tended to limit those who can be served by a hospice program. Most importantly patients must be certified as having six months or less to live if the disease runsits normal course and the patient must be willing to forgo attempts to curative treatment.
As hospices have become more successful at servicing those who are dying they have encountered more people who do not fit the requirements of this model. Many people are willing to discontinue seeking curative treatment even when the chances for effective treatment are minimal. The MHB eligibility is based on a belief that we can accurately predict six month mortality in most cases. Unfortunately we are not able to accurately predict death within six months for most individual patients. Thus there are many people who will not qualify for the MHB In addition for anyone to make use of any kind of end-of-life program there must be an end stage to the disease condition. For a significant number of people who die there is no end stage; there is a sudden decline and death.
(3)The National Hospice Organization (NHO) has drafted disease specific guidelines for determining prognosis. Various chronic diseases, such as chronic obstructive pulmonary diseases (COPD), congestive heart failure (CHF) and end-stage liver disease (ESLD), have such unpredictability that it is difficult to anticipate when death will occur in patients with these illnesses.
Investigators for the Study to Understand Prognosis’s and Preferences for Outcomes and Risks of Treatments (SUPPORT) tested the ability of currently used hospice criteria to identify patients whose prognosis for survival is less than six months. Adult patients with various chronic, non-cancer illnesses, specifically COPD, CHF and ESLD, were included unless they died or were discharged within 48 hours of enrollment. Of the 9,105 patients in SUPPORT, 2,954 were diagnosed with one of the illnesses in question. Of those, 2,607 survived hospitalization and were, therefore, potential hospice care candidates, but only 2 percent were actually discharged to a hospice service. One quarter of the potential hospice care candidates died within six months of discharge. When the broad inclusion criteria were used, 70 percent of the 923 patients identified as meeting criteria lived longer than six months, and the narrow criteria identified 19 patients referred to hospice care had a median survival of 23 days (versus 842 days for patients not referred to a hospice) The authors concluded that using the most restrictive criteria would successfully exclude patients who lived longer than six months (false-positive rate: 5.1 percent) but would also exclude almost all patients (false-negative rate: 99 percent) who would be eligible for and most likely benefit from hospice care. It remains difficult to predict a life expectancy of less than six months in gravely ill patients. Further study is needed to determine other ways to identify patients whose prognosis is poor and who would meet eligibility criteria. (4)
Medicare hospice benefit is a per diem payment that varies by region. The daily payment must cover all hospice expenditures for that patient, including medications used to treat the terminal illness, hourly pay for the nurses, and other professionals, supplies, and rental of medical equipment. The Medicare hospice per diem was cut back substantially under the Balanced Budget Act of 1997, and although some of the further scheduled cutbacks have been postponed, many of the hospice organizations are feeling the financial pinch.
Medicaid patients may also qualify for hospice benefits in some situations, and approximately 80% of employees in medium and large businesses also have hospice coverage under their health insurance plan. Most private insurance includes a hospice benefit, and 82% of managed care plans offer hospice services. When none of these sources of payment is available, many hospice organizations will provide services without charge or on a sliding scale, using funds raised through charitable contributions.(5).
Often when we consider the patient population in hospices many may believe that it consists of the terminally ill and elderly. While this is somewhat current statistics indicate that hospice patients are almost entirely white and more likely to be male.African Americans, Hispanics and patients who are uninsured or homeless are far less likely to be included. In America, you have a greater chance of dying in pain if you don’t speak English and if you are black, Hispanic, poor elderly, or a woman.
Constant shifts in the structure of the health care industry impinge on hospice, as they have on all sectors. Hospice organizations are still suffering from Medicare cutbacks imposed by the Balanced Budget Act, and while recent revisions have reduced the rate at which Medicare payments have been cut, reimbursement remains stagnant at a time when the costs of drugs and supplies are rising and hospice organizations face pressure to raise nursing salaries and benefits. Uncertainties about the future of Medicare also weigh heavily on hospice organizations. Cutbacks in private insurance coverage, especially coverage for family members, also impinge on hospice finances and make caring for patients who are not eligible for Medicare increasingly difficult. In the long term, the survival of the hospice depends on integrating stable, adequate financing for hospice coverage into whatever system of health care financing emerges from the present crisis.
Hospices have been a beacon shedding light on the issues and concerns of the dying patients and families. Yet there are many challenges for hospices some of the dilemmas:
Many physicians are reluctant to refer to hospice or make referrals too late in the dying process. Better physician training and continuing education can help to solve this problem. Secondly, Acceptance of palliative care can pave the way for hospice although specialized palliative care services based in tertiary care centers may conflict with the holistic philosophy of hospice. A realignment of these two approaches need to be sought. Thirdly, most hospice organizations are operating on a thin financial margin, squeezed by rising costs on one side and frozen Medicare reimbursements on the other. Federal budgetary surpluses may hold the answer. And finally in an ideal future, hospice concepts would be expanded outward from care of terminally ill patients to form a seamless web of caring for the elderly, the severely disabled, and the chronically ill. (7).