"CONGRESSIONAL RESEARCH SERVICE UBRARYOF~E.~ _ couenass E «V-'-=1‘: --._ ,:_ -'.- ‘I:-~ ,,,_‘_W>“M L4 Mx .-7 .- .,_ . "3 "" }'~-'- I” 3. '.':~ I ‘M-~. "7 .r‘.*.\; -. 1. ,4 .‘ y.—- 51 « . ;g* ?‘»::’?»it ~2 E z E“* Af:999 {v of Missou - Iumbia 1\\\\\\‘\’\ii\‘\K\I\('\,i\j‘\i\\\\\\\ \\ mm mm mm 0-10386072 HOSPICE CARE: A FEDERAL ROLE? MINI BRIEF NUMBER MB7825fl AUTHOR: Beiss, Kay Education and Public fielfare Division THE LIBRARY OF CONGRESS CONGRESSIONAL RESEARCH SERVICE MAJOR ISSUES SYSTEH DATE OBIGINATED 1_1_QQ41§ DATE UPDATED ggégggg FOR ADDITIONAL INFORMATION CALL 287-5700 1231 CRS- 1 HB78254 UPDATE-12/30/80 ;§sUE gsrlggmxog Hospice care is increasingly being recognized as an alternative way of caring for the terminally ill. It is a mode of care that emphasizes palliative rather than curative care for patients for whom there is no chance of a cure. Such care is designed to help terminally ill patients continue life with minimal disruption in routine activity, including working and remaining in the family environment. In general, Medicare and Medicaid do not cover hospice care services, although some private insurers have begun to do so. Policymakers are now beginning to consider what role government should play, if any, in financing and reimbursing hospice services, and what effect the hospice movement may have on the health care system. EAQEEB 9! 32. Today there are about 170 organizations in the United states studying the hospice concept, many of which have plans for establishing a hospice. According to the General Accounting Office, there are about 60 hospices in operation at this time. Hospice-care can be delivered in a variety of settings. some offer only inpatient care; others specialize in home care with a few hospital beds as backup. Still others offer both inpatient and home care. Within the institutional setting, hospice services may be provided in a separate unit or by a team that operates throughout the hospital. No matter what the setting, typically care is delivered by an interdisciplinary team composed of a physician, nurses, and some combination of social worker, psychiatrist, psychologist, clergyman, trained volunteers, and family members. Integral to the hospice concept is the philosophy that pain is preventable and can be controlled through the use of drugs. Hospices make a practice of regularly giving a fixed dosage of pain-killing drugs in anticipation of pain, not after it is severe, so that the patient is never in great pain. Currently, Medicare and Hedicaid do not recognize a hospice as a separate category of provider, although some hospices are participating in these programs within existing provider classifications (e.g., hospital, skilled nursing facility, home health agency). Some hospice services such as bereavement visits to the patient's family and drugs given in the home are not reimbursable under Medicare and Medicaid even if provided by a certified provider. As policymakers begin to consider coverage of hospice services under Medicare and Medicaid, certain issues are likely to be addressed: §g§t_§ff§gtig§ng§§; The two levels of cost effectiveness questions include: the comparative costs of conventional treatment versus hospice treatment, and the comparative costs of different models of hospice care. No extensive study has yet been undertaken to make these comparisons. There are indications that hospice care may be a more cost effective way of treating hose who can no longer benefit from medical intervention. However, there is 4150 a fear that the amount saved over general hospitalization does not merit the cost of building new facilities when there is an excess of beds in the community. Further, the incurred cost of building may benefit only a minority of those in need, while simultaneously diverting attention from demands that need to be met within hospitals. some of these concerns may be CRS- 2 I HB7825U UPDATE-12/30/80 met by hospice programs that do not rely on freestanding facilities. There is a further concern that hospice care will not substitute for existing methods of care for the terminally ill, but will result in the government paying for add-on services for this group. gliqibility; Because Medicare primarily covers people over age 65, and because large numbers of people for whom hospice care may be appropriate are under 65, consideration may be given to broadening coverage. In this regard, a comparison has been made to Medicare's end stage renal disease program which has no age limitations. Present rules regarding the conditions under which skilled nursing facility and home health care benefits can be paid may also have to be adjusted to make payment under existing programs feasible. For instance, the current requirement that a person must be honebound to receive home health benefits or have been in a hospital 3 days prior to entering a skilled nursing facility makes payment of certain hospice services impossible. Regfllatigns. To assure adequate quality care, Medicaid or Hedicare would normally develop some uniform criteria and standards for the organization, management, and quality of hospices. If a new classification of providers is not established, how would current regulations pertaining to hospitals, home health agencies, and skilled nursing facilities be modified to allow hospice reimbursement? As yet, there is no clear information on whether or not certain types of hospices perform more effectively than others. There is some concern that complex regulations designed to assure quality may stifle opportunities to provide flexible, innovative care. Effect on Exist;ng_g§§;§g_g§§g_gygtgmg Can hospice care be integrated effectively into the existing health care system? A decision is implied as to whether it is necessary to reimburse and support another new set of health services or to integrate hospice care with existing home health, nursing home, and hospital care programs. Can unused acute care beds be used effectively as hospice beds? §gagg_ggd_gbg§§; Hethods would expectably be established to insure program integrity and to avoid exploitation of public funds by some providers. Some have suggested that reimbursement be limited to nonprofit groups. ggalth_ gggpggggg Hospices may require additional types of health professionals who may need additional, specialized training. (1) §gt;Qgal_§§ggg;_;g§t;tgt§: The National Cancer Institute has funded hospice programs since 1973 when it first made an award to Hospice Inc. of New Haven, Connecticut, the first hospice in the nation. That grant has expired and NCI is currently funding three hospice groups so that it may compare inpatient hospice care with conventional care. (2) §gggggl_Agg9ggt;ng_Q§§;gg; The General Accounting Office has prepared study describing the hospice population and (a) the number and location of hospice organizations, (b) to what extent hospice care is covered by private insurance or Federal programs, and (c) how hospices are currently licensed. (GAO Rept. to Congress: "Hospice Care - a growing concept in the United States." HRD—79-50. Har. 6, 1979.) CBS- 3 HH78254 UPDATE-12/30/80 (3) Hospice Task_§9ggg: A Department of Health and Human Services (HHS) Hospice Task Force has been established to evaluate the hospice as an alternative method of care for the terminally ill. The task force is studying the cost of care, methods of reimbursement, and quality control mechanisms. (4) H2al§1.x..QaI_=e.I:i2§29iI;9-A<1I.;n.i§-222$;92. .tf.I§£A).. 22-menesrarien B£2j§2!3.§; HHS's HCFA announced in October 1978 that it plans to fund demonstration and evaluation projects on providing care to terminally ill persons. For the purposes of these projects, HEW is waiving current restrictions of payment under nedicare and Medicaid for custodial care at home, for counseling, and for pain controlling drugs used at home. Since March 1980, HHS has been paying for all hospice care provided to terminally ill Medicaid patients by 26 hospice organizations selected to participate in a 2-year demonstration project. L1.‘-'-§l§Lé.2.?£Q! During the 95th Congress, several bills were introduced dealing with hospices. H.R. 13097, which was reported by the Committee on Ways and Means on Aug. 31, 1978 and which passed the House on Sept. 18, contained a provision directing the Secretary of HE? to conduct demonstration projects to acquire necessary information and data on reimbursement for hospice services under Medicare- Representative Balgren introduced a bill.(H.R. 12358) in 1978 that would have authorized the Secretary of HEW to make a grant to a nonprofit private organization for the development of hospice standards. The measure proposed an accreditation program for agencies or organizations providing hospice care. Under H.R. 12358, HER would also have been authorized to make grants and contracts to study and demonstrate methods of providing hospice care, methods of financing the provision of this care, and the costs and benefits of hospice care. Several of the provisions in this bill were acted upon administratively within HEW when the HCFA demonstration projects were announced in October 1978. » In the 96th Congress, Representative Panetta has introduced a bill (H.R. 77uu) to provide reimbursement for hospice services under Part B of Medicare to terminally ill patients with less than 6 months to live and who choose to enroll in the program and pay required premiums. u._.__._.~ LIBRARY OF WASHINGTON UNIVERSITY Lquns - Mo, T V