In January, the Medicare Payment Advisory Commission (MedPAC) took a close look at hospice care and its coverage under Medicare. MedPAC is the agency that advises Congress on the Medicare program and recommends possible legislative tinkering with its various provisions. A transcript of a lengthy discussion held January 9 in Washington, DC, among MedPAC staff and Commissioners can be found online at www.medpac.gov/transcripts/0108-0109MedPAC.final.pdf, starting on page 259 of a 398-page document, labeled as page 3 from the second day of MedPAC's quarterly meeting.
It is interesting in a deeply wonky, public policy-focused way, particularly for anyone curious to triangulate between hospice's rather vague image with the public, the version of hospice projected by its larger and more marketing-oriented practitioners, its evolving and somewhat diminished reputation among government officials, and the variable reality of hospice care on the ground. The MedPAC report talks about structural incentives in the Medicare system favoring long stays in hospice, the correlation between length of stay and profitability, the need for closer attention to the timing of hospice admissions, marginal costs of care, the U-shaped curve of hospice costs based on length of stay, and how to reweight Medicare payments to hospice in order to achieve budget neutrality and encourage more appropriately timed admissions.
On second thought, maybe you don't want to look at this 85-page transcript, especially if what you are seeking is information about where you can find a competent and nurturing guide to deal with the fact that your own mother with cancer or Alzheimer's doesn't seem to be responding anymore to her medical treatments. One of the striking phrases from MedPAC's report is "very bad actors." For those of us who believe that hospice can be an enormous and at times even miraculous support for people at a most vulnerable time of life, it's hard to think of very bad actors inserting themselves into that intimate encounter.
Hospice professionals generally are aware of the bad actors among them but don't talk about it except among themselves, behind closed doors, believing that widespread public exposure of the problem would hurt the reputation of all hospices. MedPAC does not say who those bad actors are, how to identify them, or what to do about them once we find them. But MedPAC also thinks Medicare may be paying hospices too much and that some hospices may be inappropriately admitting some patients too soon for a benefit expressly designed for terminally ill patients with a prognosis of six months or less to live, perhaps in order to run up profits in a program that now costs Medicare somewhere around $10 billion a year.
I appreciate that many hospices struggle to keep their doors open on what Medicare now pays, some because they cover geographically dispersed areas with a top-notch workforce and take all comers with a commitment to cheerfully supply whatever is needed to maximize comfort, quality of life, relief from pain and overall peace of mind, thereby helping to facilitate what could be a truly meaningful end-of-life experience for patients and families.
But we also know that the for-profit sector of the hospice provider industry has been growing most rapidly, that some of those providers have begun bumping up against the aggregate, average per-patient "cap" on hospice reimbursement from Medicare, a problem that was once considered unthinkable, and that some are actively lobbying for legislative relief from the cap's inhibitory effects on their profit margins.
Of course that's how things are done inside the Beltway, regardless of the actor. Again, if you're trying to find the right path for your own mother, whose cancer doesn't seem to be responding anymore to her medical treatments, their messages are not meant for you. Perhaps hospice lobbying, just like the making of legislation overall or of sausage, is something best not observed too closely if you wish to retain respect for the final product -- which in this case remains the expert and compassionate care of patients with terminal illnesses and their families.