As Hospice Evolves, More Can Benefit

By Marc Rothman, MD
 Dr. Marc Rothman, Chief Medical Officer and Senior Vice President, Nursing Center Division Dr. Marc Rothman, Chief Medical Officer and Senior Vice President, Nursing Center Division

In 2010 Congress directed CMS to begin a pilot program that would expand hospice services to include patients still seeking curative treatments. Unfortunately little progress has been made, and the program’s delayed implementation was recently featured in a news story.

Hospice has traditionally only been offered to patients who have chosen to forgo further treatments aimed at curing their disease. As a result, hospice has gotten something of a bad rap. Many people think of it as a last-ditch effort, something to be pursued only when a patient is about to die. This results in under-utilization of hospice by patients with advanced diseases; the very patients who would benefit the most from the therapies and services that hospice offers. According to the National Hospice and Palliative Care Organization, in 2011, half of hospice patients received care for less than three weeks, and the average length of service was a little more than two months. This is a shame, because hospice is a six-month benefit and can bring much comfort and dignity to people at – or near – the end of life.

Though Medicare’s national pilot expansion of hospice services has yet to be implemented, some local hospices have attempted to merge curative and traditional hospice services in the way Congress and CMS are suggesting. In some areas, patients on hospice continue to receive blood transfusions, platelet transfusions, or palliative chemotherapy for example, and are enjoying a better quality of life as a result. This new approach is called “concurrent care:” physical, emotional and spiritual support near the end of life, in conjunction with previously excluded medical treatments which may not cure the disease but can significantly mitigate the symptoms.

In my mind this is a true melding of palliative care – which aims to relieve suffering and improve quality of life for patients regardless of how far along their disease is – with the traditional definition of hospice, which requires a limited life expectancy.

You might ask what will become of palliative care if the definition of hospice changes. I don’t believe palliative care would change in any significant way, but awareness of it may increase which would be a good thing. At the same time, the sting of the word “hospice” might be reduced, and so both programs may benefit. As baby boomers reach older ages and grapple with advanced disease and end-of-life issues, I think they are going to demand access to both high-quality palliative care and end-of-life care. In that sense, merging the two ideas together is a win-win for the patients who stand to benefit the most from both services. For practitioners like me – who already practice both and see them merely as two ends of the same spectrum – removing the administrative barriers between them makes perfect sense.

And what about cost? Surely including curative treatments in hospice will add to the cost of the program. But because hospice utilization reduces overall costs per patient – typically from reduced use of emergency rooms and intensive care units during the final months of life – there is hope that increased enrollment in the program might keep costs in check overall. This is precisely what the pilot program needs to study.

Hospice is one of the most underutilized programs with the biggest potential benefit to patients and their families. Any program that helps our patients preserve their dignity, honors their wishes, and supports their families during the difficult last stages of their life is worth pursuing. I’m hopeful that the Concurrent Care pilot program will start soon, and I look forward to learning from its findings.