Public institutions play a significant role in the success or detriment of both inpatient and outpatient palliative care programs. Because the vast majority of individuals dying in the United States fall into the Medicare age group, Medicare is the largest insurer for end of life health care (KFF, 2015). This becomes problematic when considering the costs accrued in the last months/years of an individual’s life. Approximately 20% of Medicare beneficiaries are living with at least 5 chronic medical conditions (S. Winn-McCorkle, personal communication, February 22, 2016 ). This number is especially astounding when considered in the context that 2/3 of Medicare expenditure goes to this specific cohort (S. Winn-McCorkle, personal communication, February 22, 2016 ). Furthermore, 25% of Medicare spending is utilized for individuals in the last year of life (KFF).
So how do these statistics relate back to palliative care and the significance of H.R. 3119? To put it simply, all of the groups mentioned above tend to be the best candidates for palliative care (S. Winn-McCorkle, personal communication, February 22, 2016 ). Not only does the addition of palliative care improve quality of life and longevity, but it has been to shown to decrease time spent in intensive care units and hospital readmissions (S. Winn-McCorkle, personal communication, February 22, 2016 ). Furthermore, because palliative care focuses on symptom management that is guided by the needs and wants of the individual, unnecessary tests, medications, and overall costs are often reduced (S. Winn-McCorkle, personal communication, February 22, 2016 ).
Palliative care focuses on symptom management that is guided by the needs and wants of the individual
While it is clear that palliative care benefits the Medicare and Medicaid budget, it is essential to examine how these public sectors can maximize the functioning of palliative care. While hospice care has been funded by the Medicare Hospice benefit for many years, palliative care has traditionally had a more difficult time being covered by the public sectors (NIH, 2010). Traditionally, Medicare does not have specific billing in place for palliative care. That being said, some aspects of palliative medicine (i.e. hospital care, treatments, medications, specialists, and social workers), can be billed to Medicare (NIH). However, Medicare beneficiaries are still often responsible for copays and fees which contrasts to the coverage for hospice care (NIH). Medicaid tends to follow suite and reflects the same potential coverage of palliative care services with its own Hospice Benefit (CMS, 2016). This however is even more problematic as the coverage varies from state to state (NIH). Patient access to palliative care varies drastically from region to region building upon existing health disparities as well as the availability of palliative care programs (Giovanni, 2012). Consequently, rural areas and states with smaller hospitals tend to not have established palliative care programs (Giovanni).
The Medicare Care Choices Model, introduced in 2014, does play a role in this as well (CMS, 2014). This model allows Medicare beneficiaries who would otherwise qualify for hospice to choose palliative care treatment in conjunction with curative treatments (CMS, 2014). The purpose of this model is to study whether or not this improves the rates of individuals using the Medicare Hospice Benefit as well as the quality of care and satisfaction experienced by patient and caregivers (CMS, 2014).
With the advent of the Affordable Care Act in 2009, the weight of public sectors has become even more prevalent. While hospice care and reimbursement were acknowledged by the act, palliative care reimbursement was not addressed. An executive summary of the Affordable Care Act and end of life care recognizes that while the Affordable Care Act did not specifically acknowledge palliative care, it does identify the need to have “Federal agencies develop a research agenda on palliative care to address issues such as the development of practice guidelines and methods of quality improvement, as well as the exploration of reimbursement options” (GWU, N.D.).
As the trend for repayment systems are navigating towards quality assurance, the patient and cost outcomes related to palliative care have an optimistic chance of receiving improved reimbursement specific for the care provided. Moreover, the general consensus from the literature continues to reinforce the need to prioritize federal and state funding for palliative care training and research. Connecting back to H.R. 3119, the bill seeks to not only improve training and research, but additionally seeks to generally improve the awareness of palliative care in the community which also has the potential to contribute to improved reimbursement.
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Centers for Medicare and Medicaid Services (CMS). (2014). Medicare care choices model. Retrieved from https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-03-18.html
Centers for Medicare and Medicaid Services (CMS). (2016). Hospice benefits. Retrieved from https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/hospice-benefits.html
George Washington University (GWU). (N.D.). The affordable care act and end of life care: Executive Summary. Retrieved from https://smhs.gwu.edu/gwci/sites/gwci/files/EndofLifeExecSummary.pdf
Giovanni, L. A. (2012). End-of-life care in the United States: Current reality and future promise-A policy review. Nursing Economics, 30 (3), 127-134. Retrieved from https://www.nursingeconomics.net/ce/2014/article3003127134.pdf
Kaiser Family Foundation (KFF). (2015). 10 FAQs: Medicare’s role in end-of-life care. Retrieved from http://kff.org/medicare/fact-sheet/10-faqs-medicares-role-in-end-of-life-care/
National Institutes of Health (NIH). (2010). End of life. Retrieved from http://nihseniorhealth.gov/endoflife/payingforcare/01.html