National End-of-Life Organizations Release Consensus Statement on Hospice, the Medicare Hospice Benefit, and Key Issues for the Future

Washington, D.C. January 9, 2009 -- Today, the National Association for Home Care & Hospice (NAHC) along with several national leadership organizations issued a consensus statement regarding the principles of hospice care and protection of the Medicare hospice benefit. Along with NAHC, the organizations standing together in sharing this unified message about end-of-life care are: the American Association of Hospice and Palliative Medicine (AAHPM), Hospice and Palliative Nurses Association (HPNA), National Hospice and Palliative Care Organization (NHPCO), the National Hospice Work Group (NHWG) and the Visiting Nurses Association of America (VNAA).

Since the inception of the Medicare hospice benefit in 1982, hospices have provided holistic care to millions of Americans in the final stage of life. Last year alone, hospices served more than 1.4 million terminally ill patients and their family caregivers. The Medicare hospice benefit is responsible for millions of people living life to the fullest until the end of life and the hospice community is dedicated not only to preserving the benefit, but enhancing it to meet the unique and changing needs of terminally ill Americans. Hospice and palliative care providers, through the support that comes from Medicare, are recognized as the leading providers of the interdisciplinary, holistic care considered to be the gold standard of end-of-life care.

The Medicare Payment Advisory Commission (MedPAC) has been looking at the growth in number of hospice providers and people served in recent years. Recommendations from MedPAC involving hospice reimbursement are expected to be released shortly. This consensus statement affirms key issues on which these leadership organizations agree.

Consensus Statement on Hospice Reform

There is broad agreement that the Medicare hospice benefit has been a resounding success. Since its addition to the Medicare system in 1982, tens of millions of patients and families have availed themselves of its unique, interdisciplinary and cost effective approach to end-of-life care. Moreover, patient and family satisfaction with this high quality health care delivery system is extremely high. Quoting from a recent independent economic study from Duke University, clearly demonstrating the cost effectiveness of the Medicare hospice benefit, “...the Medicare program appears to have the rare situation whereby something that improves quality of life also appears to reduce costs.”

Each year, a growing number of patients and families are accessing hospice care when they or their loved ones are facing the end of life. Health care professionals, as well as the public, are increasingly recognizing the value of this health care delivery system. Based upon demonstrated patient and family satisfaction with the care, the cost savings involved and the inherent compassionate philosophy of care that serves as a foundation for hospice, this growth has been encouraged by consumers and policymakers alike. Indeed, sound policy should foster growth in the Medicare hospice benefit.

Since 1982, patient demographics, treatment protocols, and public attitudes about healthcare have changed and the Medicare hospice benefit needs to keep pace with these dynamics in order to serve an ever larger, and more diverse, portion of our dying population and their families.

Payment policy is one of the areas that need to stay current so that payment appropriately recognizes changes on patient demographics and treatment protocols. Updates should be carefully considered and evidence based to ensure that behavioral consequences are understood prior to implementation. The present payment methodology has served the hospice community and the public well since its inception, virtually without change. Analysis of both current and historical patient level data is necessary to fully understand and predict future behavior and needs, and make changes that continue to provide benefits to patients and to the Medicare system.

As with any payment system, dramatic changes to the hospice benefit from established patterns of reimbursement are sure to produce displacements and unintended negative consequences. Given the nature of hospice referrals and the unique characteristics of the end of life patient demographics, unintended consequences of such changes are inherently difficult to predict. Any number of issues might warrant attention, but effectively quantifying such items in terms of behavior changes of patients and providers would be difficult. Payment reforms should be incremental, based on adequate data analysis, and need to be undertaken carefully, with effects on the patient and family in mind.

Over the past several years, MedPAC has undertaken a review of the Medicare hospice benefit. While specific reforms and enhanced accountability measures are laudable and should be encouraged, those changes should be framed in the context of a comprehensive review of the various and complex components of end of life care and how the continuum of care can be expanded to increase access for patients and families. Included in this comprehensive review of hospice should be payment methodologies, fiscal constraints review, alternative eligibility criteria, and testing of new models of care, as well as any number of other issues. The hospice community is committed to work toward these goals.

Guiding this review ought to be several clear principles. Among them are:

• Advancing hospice and palliative care providers as the recognized providers of end of life care.
• Preserving and enhancing the Medicare Hospice Benefit.
• Recognizing high quality as the standard to which all providers must subscribe.
• Ensuring accountability through transparency and fair regulatory scrutiny.
• Promoting increased access through expansion and collaboration.