Insurance rules diminish the gift of hospice care

Thank you, Investor’s Business Daily for this article of tribute to Dr. Cicely Saunders, which focuses on her many leadership traits. My interest is in the article's insightful observations about dying and the benefits of hospice.

Recently, hospice has received unfair press related to the design of hospice insurance not with the hospice care model of palliative care.

Saunders's vision for hospice was about caring for patients and accepting that at the end of life, curing the uncurable may not be what is best for the patient. She worked to keep things simple, pragmatic and evidence-based. Unfortunately, hospice insurance has abandoned these core principles. Let me review three flaws in hospice insurance design that discourage the use of hospice and make its care delivery unnecessarily complex:

1. The insurance requirement that two doctors certify a patient will die in six months. No physician wants to tell a patient they will die in six months, so they don't offer this care and wait until a patient is a few weeks from dying to raise the option. Saunders' criteria was much simpler and evidence-based - if the patient has a terminal diagnosis they qualify for hospice. This approach keeps the time factor of death off the table, making it easier for everyone to discuss hospice.

2. The insurance requirement that patients give up their regular Medicare insurance benefits in order to qualify for hospice benefits. Based on evidence from a Medicare Innovation project, patients with both regular Medicare and the hospice benefit at the same time are more willing to embrace hospice, better cared for, more satisfied and the cost of their care is one-third less. Once they experience the hospice benefit, they move from the curative treatment model that isn’t helping them.

3. The insurance rule that hospice is paid via ICD-10 coding, a process that is ridiculously time-consuming and invites fraud. The more complex we make the payment process, the more room there is to manipulate the coding to maximize payments. Venture capital is chasing after hospice because they can make a 15-20% margin by manipulating coding.

These insurance requirements are unnecessary, complicated, time-consuming and distracting, taking caregivers away from caring for patients facing numerous and important end-of-life issues.

Saunders was a great leader because she knew that if you follow the evidence and keep things simple, good things happen. Her vision and approach to end of life care gave everyone a better model of care for dying patients. Unfortunately, unnecessarily complex insurance rules are diminishing the legacy of Dr. Cicely Saunders and her gift of hospice. My book The Journeys End offers a new path forward to improve EOL care that honors the Saunders legacy.

Revisiting the art in the science of medicine

Professor Paul Lauritzen has composed a compelling piece about end-of-life care. In it, the author recounts the story of his wife Lisa dying in hospice. One excerpt in particular stands out - where the attending physician explains how patients often premeditate their own death:

“Medically,” Dr. D said, “Lisa is much better. Her vital signs are strong, and she is not experiencing any nausea. This is the good news. The bad news,” he continued, “is that your wife called the nurses in the middle of the night to say that she saw her parents on a boat outside the window beckoning her to come. I know this may not make sense,” he went on, “but we see this repeatedly in our patients. When patients report a vision like this, they almost always die within a day or two. I’m so sorry.” Lisa died just over 24 hours later. As her husband recounted, “In my wife’s last days, it was not blood work or vital signs that foretold her death, it was a dream.” These "visions" are, apparently, routine for hospice caregivers. In fact, they even have a formal name: “end-of-life dreams and visions” (ELDVs). One expert has spent ten years conducting formal research on the occurrence and impact of these dreams and visions, and has documented that they are indeed predictive of imminent death. Unfortunately, this research has not been well received in the medical community. Perhaps medicine needs to return to its roots by remembering that patient care requires both art and science. If you're interested in such an approach, I encourage you to check out The Journey's End.

Why shouldn't everyone benefit from Hospice care improvement opportunity?

“CMS to Allow Hospice Care During VBID Extension.” That is the title of a recent article in Hospice News. In essence, it is declaring is that patients will now be eligible to receive both traditional Medicare and Hospice Care in Medicare Advantage Plans. My question is - why give this care improvement and cost savings opportunity to only private insurers?

Medicare is failing financially and it decides to give away the $2.3 billion dollar savings that Medicare gets from Hospice annually!

The policy logic of this strategy is flawed at best. The Hospice Benefit needs a major overhaul because evidence demonstrates it could improve end-of-life care and save Medicare billions of dollars. Major changes like:

1. Eliminating the six-month death certification and replace it with a terminal diagnosis

2. Allowing patients to receive curative care and comfort care simultaneously

3. Expand the home care benefit in hospice to make it a more viable option for families.

Going into Hospice compared to receiving ineffective and expensive hospital care, drugs, and treatments would save money and improve care.

Medicare funding challenges will not be solved with incremental change. End-of-life care in our nation will not improve without dramatic and simple payment and insurance change by Medicare. My book, The Journey’s End offers a thoughtful analysis and concrete recommendations based on sound economics to address these concerns.