Expanding Hospice Care to Include Concurrent Care.

New guidelines, adopted in March, will expand Medicare and Medicaid and to cover hospice services that include "concurrent care." Both Christian Sinclair and Diane E. Meier are quoted in the article. From Amed News:

The law also calls on the Health and Human Services secretary to conduct a three-year, budget-neutral demonstration project of concurrent care for Medicare patients at 15 hospice-care sites.

The use of hospice and palliative care has grown steadily in recent years. Nearly 1.5 million patients received hospice care in 2008, up 36% from 2004, according to the National Hospice and Palliative Care Organization, which represents 80% of the country's hospices. Yet physicians offering this alternative to patients often receive hostile responses from patients and families who view it as the final step through death's door.

The median length of stay in hospice is less than three weeks.

"There are people who, when talking about hospice, they'll say, 'Don't say that word in front of my loved one,' " said Christian Sinclair, MD, associate medical director of Kansas City Hospice & Palliative Care in Missouri. "We get such a visceral reaction to changing toward a palliative care goal."

Choosing hospice care can be especially scary for patients on Medicare, said Diane E. Meier, MD, director of the nonprofit Center to Advance Palliative Care. Some private health plans cover concurrent care, but for Medicare patients -- and, until recently, children covered by Medicaid -- choosing hospice has meant giving up aggressive treatment efforts.

"The Medicare hospice benefit is the jewel in the crown of Medicare in that it's truly interdisciplinary care," said Dr. Meier, director of the Hertzberg Palliative Care Institute at New York's Mount Sinai Medical Center. "But in order to get this wonderful benefit that is hospice, you must, on the flip side, sign a form giving up the right to regular Medicare. People feel, quite rightly, that it's like signing a death certificate."

The benefit this change offers patients, families and carers at the end of life is increased time in hospice programs, greater assistance to those facing end of life planning and decision-making, and more flexibility in where they are treated.

"You go from one phase to the next phase with something to hold on to as you make that transition," Schumacher said. "Many people say, 'I wish I'd come to hospice sooner.' "

Getting patients into hospice earlier gives them access to expert advice to help decide whether curative efforts are worth pursuing further, Schumacher said. "We believe involving hospice sooner will help people forgo nonproductive treatment."

The new law also calls on Health and Human Services to conduct a pilot program to test the efficacy of the changes:

The law also calls on the Health and Human Services secretary to conduct a three-year, budget-neutral demonstration project of concurrent care for Medicare patients at 15 hospice-care sites.

The demonstration project will test whether paying for concurrent care helps patients and saves Medicare money. Then the HHS secretary will recommend to Congress whether to change the hospice-care payment policy. A Centers for Medicare & Medicaid Services innovation center created in the health reform law also may be able to act on the recommendations. Hospice care cost Medicare $11.2 billion in 2008, according to the Medicare Payment Advisory Commission.

Some of the greatest benefactors of this change may be ill children:

In the meantime, children with terminal illnesses and their families should benefit from Medicaid's coverage of concurrent care efforts, Dr. Sinclair said.

"In pediatrics, the prognosis for patients can be a lot harder to define," he said. "Having a concurrent care model is helpful, because those families need a lot of help, especially from psychosocial and the other resources that hospice can provide."