'Open Access' Hospice; Allowing Patients to Continue Treatments

[Guest guest]

A Chance to Choose Hospice, and Hope for a Cure

By REED ABELSON

Published: February 10, 2007

The American health care system has long given patients a terrible

choice: people told that they have a terminal illness must forgo

advanced medical treatment to qualify for hospice care. Cancer

patients have to pass up chemotherapy, for example, or patients with

kidney failure must abandon dialysis.

Forcing patients into this either-or decision has prompted many who

might benefit from a hospice program to instead opt for expensive

hospital care that may end up costing Medicare and other insurers far

more.

But now, some hospice programs and private health insurers are taking

a new approach that may persuade more patients to get hospice care

for

the last months of life. These programs give patients the medical

comfort and social support traditionally available through hospice

care, while at the same time letting them receive sophisticated

medical treatments that may slow or even halt their disease.

Hospice care is intended to help patients and their families better

cope with the end of life by providing social services and special

care.

Experts say that if the new approach catches on more broadly, more

patients who would benefit from hospice care will actually enter

hospice programs — and enter them earlier. And more patients, they

say, could avoid the costly, crisis-ridden final weeks in a hospital

that often still represent the American way of death.

In 2005, only about a third of the 2.4 million people who died in

this

country were in hospice care. Perhaps twice that many patients should

have been in hospice programs, according to specialists in the field.

And even many of those who entered hospice care did so only at the

very end of their illnesses, spending a week or less in a program

that

ideally would have helped them cope with the final six months or year

of life.

For too many of those patients, " that's not hospice; it's last

rites, "

said Dr. W. Rowe, the former chairman and chief executive of

Aetna, one of the big insurers that is rethinking hospice care.

UnitedHealth is another insurer that now lets hospice patients also

receive advanced medical treatments. Meanwhile, some of the nation's

4,200 hospice programs are offering advanced medical treatment even

when they are not paid more to do so.

The new approach, which proponents call " open access " hospice, is an

example of the efforts by some insurers and health care providers to

try to fix specific problems in the nation's medical system even as

politicians and businesses weigh sweeping health care overhaul

proposals in Washington. Being able to have potentially

life-prolonging medical treatment makes all the difference to hospice

patients like Marko, 42, who has advanced gastric cancer and is

recovering from recent surgery for his condition.

" I probably would not have elected to go to hospice, if curative care

wasn't an option, " Mr. Marko said. He is considering taking

chemotherapy even as he receives the kind of additional care

available

through a hospice program, like visits from a nurse and a massage

therapist at his home in Covington, Wash. Both types of care will be

paid for by the Aetna coverage he receives through his employer.

Dr. Rowe, whose medical specialty is caring for the elderly and is

now

a health policy professor at Columbia University, pushed Aetna to

begin an experiment two years ago to pay for traditional medical care

even while covering hospice services, usually at home, like nursing

care or a home health aide.

Many doctors say the either-or approach, if it ever made sense, is

less valid now that continued advances in medicine can allow even

patients with very advanced disease to benefit from new treatments.

" The whole dichotomy is entirely false, " said Dr. Ira R. Byock, the

director of palliative medicine at the Dartmouth-Hitchcock Medical

Center in Lebanon, N.H.

There are many reasons people are slow to consider hospice care — not

the least of which is acknowledging that they are dying.

But Dr. Byock rejects the notion that the only point of hospice is to

help people die. He says that by offering nursing care and palliative

medicine to relieve pain and improve the quality of life, hospice

care

can benefit some people so much that they become well enough to leave

the programs. The Aetna experiment, for which nearly 400,000 of its

roughly 15 million insured members are eligible, provides some

evidence that people will take advantage of hospice care if they do

not have to give up other treatment intended to prolong life.

Mr. Marko said that once he learned that Aetna would not ask him to

forgo chemotherapy, there was no reason not to sign up for the

hospice

services that allowed him to be more comfortable at home with his

wife, Amy, and their three young children. His massage therapy makes

him feel better, for example, and he plans to try the acupuncture

available through the program.

" What's to lose? " Mr. Marko said.

What can be gained is more time to take advantage of hospice's

benefits. One woman in the Aetna experiment who had breast cancer was

able to continue chemotherapy even as she enrolled in a hospice

program that offered the nursing care she needed before she died.

" She just wasn't ready to give up, " said Sharon Brodeur, a nurse and

Aetna administrator who helped develop the experimental program. The

patient probably entered the program two or three months earlier than

she would have if she had had to give up chemotherapy, Ms. Brodeur

said.

The Aetna initiative and other open-access programs are still the

exceptions, though.

For example, Medicare which spent about $9 billion on hospice

benefits

last year out of its total spending of $406 billion, requires

patients

to give up regular medical coverage if they enter a hospice program.

Medicare officials say that patients can opt for hospice care and

then

change their mind, resuming traditional coverage. And they say that

nothing in Medicare's rules prevents hospice programs from providing

a

full range of medical treatments.

But many hospice programs do not offer advanced medical treatments

because they say they cannot afford to. Medicare pays a provider

about

$130 a day for routine hospice care in the home, regardless of the

patient's individual condition. The agency, which introduced the

benefit in the mid-1980's, based its rules on the assumption that it

would be too costly to pay for both hospice care and for treatments

aimed at prolonging life.

Many experts, though, say that thinking is misguided because it

causes

patients to spend their last days in a hospital receiving expensive

care they may not even want, or to frequently return to the hospital

because managing their disease is too much for a family to handle.

" What they're doing instead is paying for unnecessary emergency room

visits, " said Dr. Diane E. Meier, a professor at Mount Sinai School

of

Medicine in New York and an expert in palliative care.

Medicare officials, though, cite the growing popularity of hospice

programs as an indication that the benefit is valuable in its current

form.

Hospice care has been allowed to " thrive and prosper, " said ce

, the director of chronic care policy for the Center for

Medicare Management. But he also emphasized that patients who still

wanted aggressive medical treatment had the option of sticking with

traditional Medicare coverage.

Hospice is " not all things to all people, Mr. said.

Many people in the field say that Medicare's fixed-payment system

discourages some hospice programs from accepting patients who need

expensive treatment.

The perverse incentive is to take the cheapest patient, " said Carolyn

Cassin, the chief executive of Continuum Hospice Care, who said such

a

patient would be someone who had already given up hope and required

very little medical care. Continuum Hospice Care is part of the

hospital system of the same name in New York and is among the small

number of hospice programs that makes a point of taking even those

patients who want sophisticated treatment.

Because Continuum Hospice cared for 2,700 patients last year, on a

budget of about $42 million, the program is large enough to absorb

the

cost of some very expensive patients, Ms. Cassin said.

" You're never going to have to choose between treatment for the

disease and care from us, " she said, noting that about 40 percent of

Continuum Hospice patients received advanced medical therapies.

When 76-year-old Tirone, who had late-stage lung cancer, was

discharged from the hospital late last year, for example, he was able

to continue his radiation treatments and still enroll in Continuum's

hospice program. Social workers and nurses managed his care at his

West 57th Street apartment in Manhattan, until his death on Tuesday

evening.

The social worker assigned to Mr. Tirone " tried her best to make

Charlie comfortable, " said Abbassi, a longtime friend who

helped care for him.

Many other hospice programs are exploring the Continuum-style of open

access, accepting patients with insurance at the end of life who may

want and need aggressive medical treatments.

" This has been a big movement and a big discussion over the last five

years, " said Malene , the chief executive of Capital Hospice in

Falls Church, Va., which cared for about 5,100 patients last year.

Many hospice programs, though, are too small to spread their costs,

which would allow them to take patients needing expensive treatments.

And if they meet basic state and Medicare requirements that include

offering access to a nurse and a doctor 24 hours a day, hospices can

essentially pick and choose which treatments to offer as long as they

are meeting a patient's needs.

" There is a huge variation in what programs provide, " said Dr. Mark

Leenay, the medical director of palliative initiatives at

UnitedHealth, the big insurer.

Because Medicare does not collect detailed data about the medical

treatments a hospice patient receives, there is very little

information about what services are actually being provided. Some

argue that Medicare should simply drop the requirement that patients

forgo other coverage if they want hospice care.

As part of a much broader effort toward revamping health care,

Senator

Ron Wyden, Democrat of Oregon, has introduced legislation that would

end that requirement. He says that the change would not significantly

raise Medicare's spending, but that it would give people more control

over the way they die.

" People don't want government making their choices, " he said.

One insurer, Blue Cross and Blue Shield of Rhode Island, which

typically pays for treatments like chemotherapy as a way to relieve

pain even while covering hospice care, says it has not seen a

significant increase in the use of medical services because of this

broader coverage.

At Dow Chemical, an employer in the Aetna experiment, the company's

executives agreed to pay for the broader coverage because " it's the

right thing to do, " said Steve Morgenstern, who manages Dow's health

plans.

Aetna plans to continue its experiment, which in its first year

increased the average length of a hospice stay to 34 days, up from

27.

The insurer's chief medical officer, Dr. Troyen Brennan, predicts

that

the company will probably end up extending its coverage to more of

its

insured members.

" Looking at the preliminary data, everything suggests we should move

forward, " he said.

Dr. Rowe, the former Aetna chairman, said insurers should not be in

the business of forcing people to give up hope. " When I was in

practice, " he said, " I wouldn't do that to a patient. "