Hospice and Palliative Care worker services; counseling; short-term Background inpatient hospice care; medical appliances and supplies; drugs and biologics for pain relief and Palliative care is defined as that which relieves symptom control; home health or hospice aid suffering and improves quality of life for people services; physical, occupational and speech with serious illnesses, no matter whether they can therapy; and bereavement support. To be be cured. Hospice is a delivery system for which eligible to elect hospice care under Medicare, eligibility is defined by public and private payers. patients must be certified by physicians as Not all palliative care is hospice, although hospice having a life expectancy of six months or less if care is always palliative. the terminal illness runs its normal course. Eligible Medicare patients must file an election The philosophies underlying hospice and statement with a hospice provider. The palliative care are similar; however, there are statement must include a number of elements, important differences. Whereas most hospice including the patient’s acknowledgement that care is provided to patients in their homes, non- he or she: 1) has been given a full hospice palliative care is usually provided in understanding of the palliative rather than hospitals, cancer centers and clinics. Additionally, curative nature of hospice care; and 2) waives hospice is a specific type of palliative care for all rights to Medicare payments for services people who likely have six or fewer months to live related to the treatment of the terminal illness and no longer wish to pursue curative treatments. and related conditions. Patients can revoke Palliative care can be provided at any stage of their election to hospice care at any time and illness regardless of whether or not patients return to standard Medicare coverage. continue receiving curative care. Curative treatments are those which modify underlying Some stakeholders question whether disease rather than exclusively manage Medicare’s requirement that patients forego symptoms such as pain or stress. curative care in order to elect the hospice benefit still makes sense in today’s health care environment. Chemotherapy, radiation and Medicare’s hospice benefit blood transfusions are routinely provided to seriously and terminally ill patients, and the Medicare is the largest insurer of end-of-life distinction between what constitutes life- medical care and the primary payer of hospice prolonging and end-of-life treatment is care, although private insurers also offer significantly less clear than it once was. A hospice coverage. In 2014, more than 1.3 federal demonstration project called the million people received Medicare hospice Medicare Care Choices Model (MCCM) is services from 4,100 certified for-profit and non- currently testing the provision of concurrent profit providers at a cost of $15.1 billion. hospice and curative care. However, critics question whether payments to hospices under The hospice benefit was introduced to the this model are sufficient to deliver true hospice Medicare program in 1983 to provide services. interdisciplinary, team-based services including: nursing care; physicians’ services; social

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Medicare payment & costs Where the AMA stands

Medicare pays for hospice care using per diem The American Medical Association believes that payment categories encompassing four levels thoughtfully designed, financially sustainable of care: routine home care; general inpatient hospice and palliative care programs are care; continuous home care; and inpatient essential to improving the life quality of respite care. Service intensity add-on payments seriously ill patients. The AMA’s extensive are also made when hospice provides direct policy recognizes the benefits of hospice and patient care by a registered nurse or social palliative care to patients and their families and worker during patients’ last seven days of life. supports: In keeping with the hospice philosophy, routine home care accounts for the large majority of • Improved payments for health care hospice payments. practices caring for terminally ill patients. • Broadening patient eligibility criteria Despite growth in hospice utilization, fewer than beyond six-month prognoses under half of Medicare patients elect hospice services, Medicaid and Medicare hospice benefits. and more than a quarter do not enroll until their • Allowing hospice patients to utilize final week of life. Underutilization of Medicare’s appropriate palliative therapies that treat hospice benefit is likely due in part to reluctance underlying disease if patients respond to among patients to discontinue life-prolonging such therapies. care. Although the Medicare program does not • Allowing community physicians to remain require patients to abandon curative treatments involved in the management of their in order to enroll in hospice, Medicare will not patients’ hospice care. pay for them. As a result, it is not financially • Encouraging all physicians to become viable for hospices to provide life-prolonging skilled in palliative medicine. treatments since they receive no additional • Encouraging physicians to be familiar with payments for them. local hospice and palliative care resources, as well as clinical practice guidelines The literature on hospice costs to the Medicare developed by national medical specialty program has produced mixed results, with societies. some studies showing large cost savings among hospice patients – particularly among Additionally, the AMA supports ongoing early hospice referrals – and others pointing to research in the fields of hospice and palliative higher costs of care, especially for long-term medicine, and urges the Centers for Medicare enrollees. Many studies have shown that early & Medicaid Services to: palliative care interventions improve patients’ quality of life and symptom burden. Palliative • Thoroughly study Medicare’s hospice care providers – either primary physicians who benefit, including its structure and payment have the skills to care for the seriously ill, or methodology. those trained in palliative medicine – can also • Identify ways to optimize patient access to help patients transition to hospice or end-of-life palliative care, and to provide appropriate care. Palliative care is most commonly provided coverage and payment for palliative by hospitals, and many palliative services are services. covered by public and private insurance. • Continue pilot testing a variety of models

for providing and paying for concurrent hospice, palliative and curative care. C

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