Academic journal article Generations

The Current and Potential Role of Palliative Care for the Medicare Population

Academic journal article Generations

The Current and Potential Role of Palliative Care for the Medicare Population

Article excerpt

Palliative care is a relatively new interdisciplinary specialty focused on improving quality of life for persons with serious illness and their families. Palliative care teams, composed of physicians, nurses, social workers, and chaplains, provide an added layer of support to seriously ill patients of any age, their caregivers, and their healthcare providers, regardless of prognosis. Palliative care teams assess and treat symptoms; support decision making; help match medical treatments to informed patient and family goals; and, identify and coordinate resources and services to ensure a seamless care plan across a spectrum of settings (i.e., hospital, nursing home, home).

Palliative Care and Its History within the Medicare Program

In the United States, palliative care is provided both within and outside hospice programs. Codified as the Medicare Hospice Benefit in 1982, hospice is designed to provide comprehensive, interdisciplinary, team-based palliative care, mostly in a place the patient calls home, for dying patients with a predictably short prognosis of fewer than six months. Hospice care is appropriate when patients and their families decide to forgo curative or disease-directed therapies in order to focus solely on maximizing comfort and quality of life.

In contrast, palliative care outside hospice is offered independent of the patient's prognosis and simultaneously with life-prolonging and curative therapies for persons living with serious illness. Ideally, palliative care is initiated at the time of diagnosis of a serious illness and continues concurrently with disease-modifying treatments. Palliative care may be primary, secondary, or tertiary. Primary palliative care should be part of what all clinicians provide (such as pain and symptom management, advance care planning). Specialists provide secondary palliative care for unusually complex or difficult problems. Tertiary palliative care includes research and teaching in addition to specialist-level palliative care expertise.

Modern palliative care in the United States has developed in response to important statutory limitations of hospice. Under the Medicare Hospice Benefit, and private insurer hospice benefits modeled after Medicare, services are restricted to persons with an expected prognosis of fewer than six months and those willing to forgo disease-directed treatment. Most hospices are unable to cover expensive palliative treatments (e.g., radiation therapy for painful metastatic disease) under the average Medicare per diem rate of $156 per patient, per day.

Historically, these restrictions left countless patients to suffer with the stress and symptoms of serious illness and its treatment without expert palliative care. In response, palliative care programs initially were established in teaching hospitals, with teams, commonly known as interdisciplinary consultation teams, composed of physicians, nurses, social workers, and chaplains. Over the past decade, palliative care programs have spread rapidly, and now almost 90 percent of 300-plus bed and nearly twothirds of all hospitals with more than fifty beds report having palliative care teams (see Figure 1, page 114) (National Palliative Care Registry, 2014).

Palliative care services also have expanded to clinic-based practices and community home-visit programs. The proportion of seriously ill Medicare beneficiaries receiving palliative care services outside of hospice is unknown. Although more than 40 percent of Medicare beneficiaries are enrolled in hospice at the time of death (Teno et al., 2013), hospice length of stay often is short, with a median of fewer than three weeks and more than a quarter of patients enroll within the last three days of life. Additionally, intensive care unit admissions and burdensome healthcare transitions in the last month of life have increased during this time period (Teno et al., 2013), suggesting that hospice use tends to follow a series of high-cost, acute-care episodes in the months before death. …

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