Eli's Hospice Insider

The messaging appears be on target: Aggressive end-of-life care is a lose-lose proposition.

Legislation in play could put key palliative and hospice care issues on the table as the healthcare reform debate begins to heat up in Congress. The proposals are helping to counter end-of-life care providers' fears that the reform effort could leave them out in the cold.

Capturing center stage: Sens. John D. (Jay) Rockefeller IV (D-W.Va.) and Susan Collins (R-Maine) recently reintroduced the Advance Planning and Compassionate Care Act, which is more expansive than the original version.

The bill is now in the Senate Finance Committee.

In introducing the legislation, Sen. Rockefeller noted that "80 percent of all deaths occur in hospitals -- the most costly setting to deliver care -- even though most people would prefer to die at home." In fact, "current studies indicate that around 25 percent of all Medicare spending occurs in the last year of life." In addition, research shows "significant variation" in endof-life spending based on geography and hospital "without evidence that greater expenditures are associated with better outcomes or satisfaction,"

the senator concluded. (For specific provisions in the bill, see the sidebar on this page.)

The Rockefeller bill represents a "much broader attempt to improve access to palliative care upstream from terminal care where people have six or fewer months to live," says Diane Meier, MD, director of the Center to Advance Palliative Care, and professor of geriatrics and internal medicine at Mount Sinai School of Medicine in New York City.

Better approach: Looking at the big picture is essential to rein in overall costs due to inappropriate care, in Meier's view. If Medicare simply focuses on reining in hospice spending as a "silo," it can control those costs, she says. However, then "those costs go somewhere else -- to the emergency departments, inappropriate chemotherapy, PET scans, doctor visits, etc."

The fact that the Rockefeller bill looks at the broader continuum of chronic illness represents progress, agrees Janet Neigh, VP for hospice programs at the National Association for Home Care & Hospice (NAHC).

The act includes many hospice issues that NAHC has been pursuing for years, she adds. These include "ensuring portability of advance directives, requiring physician education in endof-life care ... making hospice a required Medicaid benefit, Medicare hospice payment model demonstration projects, ensuring core end-of-life care quality measures, and hospice surveys at least every 36 months."

More Efforts in the Works Most recently, Sen. Mark R. Warner (D-Va.) introduced the Senior Navigation and Planning Act of 2009 which, starting in 2011, would provide Medicare coverage for a new advanced care management benefit administered by hospice providers, according to a statement from Warner's office "The advanced illness care management benefit includes palliative care consultation services, patient and family counseling, respite services, and in-home caregiver training, while also allowing for the continuation of curative treatments," states the release.