Clinicians are increasingly seeing a need to revamp the Medicare Hospice Benefit in ways that better support the needs of patients with life-limiting conditions, as well as their families and caregivers.
Evolutions in medical treatments and in terminal conditions have reshaped patients’ end-of-life care trajectories, according to Dr. Rachel Jordan, board-certified family nurse practitioner and secretary for the Maryland Board of Nursing. Jordan serves as director of nursing and clinical advocacy and of legislative affairs at Hospice of the Chesapeake.
Despite swelling demand, hospices’ ability to diversify and expand the scope of their person-centered services is being limited by regulatory frameworks that need an overhaul, Jordan said during a recent Hospice News ELEVATE podcast.
“Hospice is a beautiful thing, but one of the ways that it’s written and administered in America is almost like a hard stop,” Jordan told Hospice News during the podcast. “[Patients] have to give up access to certain things they hold valuable to life, like dialysis or palliative radiation, and so that hard stop feels really cold. A lot of people are very hesitant to enroll in hospice. That’s a big barrier. We have to address the policies.”
Barriers, opportunities in policy innovation
Calls for changes to hospice eligibility and length of stay have been growing louder among industry stakeholders, policymakers and providers. A main concern being voiced to the U.S. Centers for Medicare & Medicaid Services (CMS) is that the current six-month prognosis poses limitations on access, utilization and quality of care.
Clinical advancements in medicine, technology and diagnostics have resulted in patients living longer with serious and terminal conditions, Jordan said. But eligibility and length of stay issues in the hospice benefit serve as significant challenges for growth and sustainability. Hospice regulations have not kept pace with rising demand for upstream support or innovations in health care, she indicated.
Hospice policies need to integrate more palliative care inroads to better address access and utilization challenges, according to Jordan.
“We have more people living with cancer and they’re doing treatment that’s not geared to curing, but more palliative in nature,” Jordan said. “These are things to improve the quality of life, yet the current hospice benefit says there’s no coverage for those things. It’s important that we update the policies and procedures now so that they reflect where medicine has advanced to. Hospice needs to grow with that body of knowledge so that we can manage these patients appropriately and really improve quality of life. We have to be ready to shift and pivot.”
Current hospice policies do not sufficiently support the ability to expand caregiver and family services, according to Dr. Christopher Paredes, family physician and geriatrician. Paredes is regional director of Northwell Health’s House Calls Program.
A growing number of families will be caring for the nation’s swelling aging population, and hospice reimbursement structures offer limited avenues to support their physical, practical and emotional needs, Paredes indicated. Though respite is part of the services that hospices receive reimbursement for, family caregivers often need this support much further upstream, he said.
Currently, a patchwork of laws exists to aid caregivers when it comes to respite, family medical leave policies and financial support.
“What we have in terms of policies in Medicare … It’s not reflecting what’s happening now,” Paredes told Hospice News during the podcast. “The population has shifted to where there’s going to be more chronically ill people than healthier people. Things have to change in terms of reimbursement. A lot of policies have to change for everyone to get this kind of care.”
Policymakers should also consider the impact of rising demand on widespread health care staffing shortages, particularly when it comes to hospice and palliative care professionals, according to Paredes. Policies that better address the significant workforce shortages are needed, he added.
Medical students receive limited exposure to hospice and palliative care, as do clinicians from other disciplines, Paredes said. Having policies that expand education and training opportunities in this field would go a long way toward improvement.
Though lawmakers have introduced legislation aimed at addressing hospice workforce issues, none of these efforts have moved the needle substantially thus far, Paredes indicated.
Among the legislative moves has been the recent reintroduction of the Provider Training in Palliative Care Act in August. If enacted, it would allow members of the National Health Service Corps. to defer their service for up to one year to allow for additional training in palliative care. The Palliative Care and Hospice Education and Training Act (PCHETA) was also reintroduced in July, seeing several iterations in recent years. The bill aims to bolster shrinking resources through federal support of staff training, education and awareness.
“Educating the future is another way to make sure that people can get this kind of care that they need,” Paredes said. “[It’s] starting to educate about hospice, palliative care, home-based care to the medical students, nursing students and all the different interdisciplinary [professionals]. Everyone studying medicine or health care should understand what they can do to help our aging population. Another way of addressing this issue is implementing more structure, more instruction on this population and teaching other clinicians.”
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