THE DOCTOR IS IN / OP-ED BY DR. ADIL MANZOOR
Medicare’s hospice benefit is one of the best things that have happened to our health system, but it has its flaws, like many other parts of our healthcare.
Before I dig into it, let me briefly explain hospice care. It is a special kind of care that focuses on terminally ill people. So, it is basically care given to people with advanced, life-limiting illnesses, like cancer and end-stage dementia. The point of this type of care is not to cure the patient – far from it; rather, it is to provide comfort care to patients that have come to terms with the fact that they will die soon.
This way, people with terminal illnesses can live out the last few months or years of their lives as comfortably as possible. Also, it relieves the financial and emotional burden on the families of such people who are already obviously going through a tough period.
In 1982, Congress recognized the need to have a hospice benefit under Medicare, and rightfully so. The definition of terminally ill under this benefit is six months to live. This benchmark worked fine for several years until it didn’t anymore.
At the early stages of implementing the benefit, the overwhelming majority of people benefiting from the program were cancer patients. Doctors could predict when the six-month benchmark was in effect for cancer patients to a very reasonable degree.
Fast forward to 2021, and half of the patients on the benefit are dementia patients. Unlike cancer, accurately predicting when a dementia patient has six months to live is challenging. This is because a patient with dementia can stabilize after comfort care and end up living far longer than expected.
When patients have dementia and are certified to be eligible for hospice care, they start getting the care. But because of the nature of the condition, many of them can improve and still be very much alive after six months. At this junction, they become ineligible for hospice care. The implication is their condition worsening, and expectedly too.
If they go back to their doctors for reevaluation and the doctor finds out their condition has deteriorated to the point where they have six months to live, they can be recertified for the hospice care benefit.
Examining this from a theoretical viewpoint raises doubt and controversy about how appropriate a principle like this is. However, there is no such doubt in reality – the principle of losing eligibility, letting the patients get critically sick again, and then recertification is absolutely horrendous.
In practice, there’s the constant headache of neglecting the required health care services an end-stage dementia patient has to comply with the flawed six-month benchmark for the condition. Doctors know very much that the comfort care services have to continue, but when the hospice benefit regulations kick in, the care services have to stop.
Personally, I think it is worse than not offering any care in the first place. Here’s why. Hospice care creates a false hope of patients living a far longer life due to the stabilization of their condition. The moment the care is stopped, patients spiral back into a critical condition, making it even tougher for them and their families to bear as they have shared the relief and happiness of potential stabilization. In short, the patient’s family has to go through emotional and financial stress again every time the patient is off the care.
If this painful cycle of expiration of eligibility and recertification of Medicare hospice benefits continues, it is only a matter of time before the patient and their family give up on the system and just let nature run its course.
There have been a few modifications and adjustments to the hospice benefit. Still, none of these has considered people with end-stage dementia who don’t conform to the traditional six-month benchmark. I hope this changes soon, perhaps with a system that reduces the level of care services for these patients but increases the benchmark for living.
This article was written by Dr. Adil Manzoor DO, a Board Certified Internist & Board Eligible Pediatrician, who works as a Hospitalist, and Emergency Room Physician. He is also the current President of Garden State Street Medicine, a non-profit organization whose sole purpose is to provide free preventive and acute urgent care services for the homeless. He is also the co-founder of his own unique medical practice Mobile Medicine NJ.
References
- https://www.washingtonpost.com/health/2022/03/26/medicare-alzheimers-dementia-hospice/
- https://www.beckerspayer.com/payer/medicare-rules-make-hospice-harder-to-access-for-end-stage-dementia-patients-study-finds.html
