Preserving the Medicare Hospice Benefit

There is nothing in life more uncertain than its end. Too many of our friends and loved ones have died too soon. But just the same, we have all seen those who have survived months or even years beyond the best doctors’ prognoses. These are miracles, triumphs of the human spirit, and show us how a caring environment can sometimes sustain us longer than modern medicine.
 
That is one of the reason many families make the decision to bring their loved ones into hospice care to face their final days. Hospices are designed to address the stress and anxiety that comes from the process of saying goodbye and facing the end of life, as well as to minimize pain for those whose disease has progressed beyond the potential for a cure.

I was a member of the House of Representatives when the Medicare Hospice Benefit was created in 1982. Enactment of this important benefit remains an achievement in which my colleagues and I continue to take great pride. I have long advocated for hospice care because its supportive environment can help terminally ill patients do better, and actually live longer, than they might otherwise. That is why the hospice benefit in Medicare was designed without hard and fast rules on the length of time patients could receive services. Instead, Congress left it up to doctors to determine whether a terminally ill patient has a prognosis of six months before initiating hospice care. In most cases certification by two doctors is needed to establish a patient as eligible for hospice.
 
Hospice care in the United States -- and the population it serves -- has undergone significant changes over the last 30 years. When the hospice benefit began, the greatest need for this service was seen among individuals with cancer. Now we see patients with a greater variety of diagnoses entering, and benefitting from, hospice care. The technologies available for care in the home and prescription medications (and their costs) have also changed considerably. For these and other reasons, the hospice payment system is currently undergoing a thorough review and is expected to be revamped over the next few years. We also anticipate greater transparency as the federal government develops and implements a hospice quality reporting program.  These changes are needed – and will help hospice programs respond to the evolving needs of the public they serve.
 
However, despite change on many fronts, it remains a difficult task for physicians to predict with certainty how closely a particular patient’s disease trajectory will track that of other patients with comparable conditions and comorbidities – in short, to predict how long any one patient may live.  Prognosis remains an inexact science. Each individual’s response to hospice care is distinct. This is why the hospice team is required to review treatment plans on an ongoing basis and make adjustments to the changing needs of the individual patient.  
 
As Congress and the regulatory agencies take steps to increase accountability throughout the Medicare program, I would urge that they keep in mind that the very singular nature of each patient’s response to care is an important element of the hospice “equation” and something that cannot always be anticipated. This recognition will go a long way toward protecting the intent that my colleagues and I had when we enacted the hospice benefit. More importantly, it will preserve this unique benefit so that it can continue to bring greater comfort and meaning to the lives of terminally ill individuals and those who love them.

Breaux is senior counsel to Patton Boggs LLC, with a particular focus on the areas of energy law and health care; included among his clients is the National Association for Home Care & Hospice (NAHC).

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