Week 7: 2/22-2/28-The Influence of Public Sector Institutions

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).

   2010    ◦ 171 new referrals    ◦ 415 established patient visits      An LCSW was added, split between hospice and pal...
Palliative care serves as an important aspect of the health care team (2)

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 percentage of hospitals with palliative care programs varies from state to state (3)

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.).

The aging population will need palliative care access (4)

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.

Photo Credits

1. Header photo: https://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/palliative-care-and-rehabilitation-medicine/index.html

2. http://www.slideshare.net/Kindredhealth/palliative-care-across-the-continuum

3. http://www.slideshare.net/ctsinclair/hospice-palliative-care-missouri-health-net-aug-2009

4. https://publichealthwatch.wordpress.com/2014/03/15/how-the-affordable-care-act-opens-the-door-for-two-vulnerable-populations/


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

Week 5: 2/8-2/14-Historical and Contemporary Roles

The concept of palliative care is a relatively modern connotation and much of its history relates directly to hospice care. Hospice care traces back to as early as the 12th century where “hospices” were maintained by religious oversight and provided aid and care to the ill or dying (PCCSA, 2012). This concept continued on and off until the 19th century in the United Kingdom and France where religious orders cared for both the terminally ill and those who were deemed incurable (PCCSA).

Palliative care as a specific specialty came to the forefront in the 1950’s when Dr. Cicely Saunders recognized the need for an interdisciplinary team to manage the “total pain” that a dying person experiences (Loscalzo, 2016). By 1960, the concepts of modern palliative care and hospice were still met with resistance. In 1963, Saunders came to the United States from London to give a series of lectures to the Yale School of Nursing regarding hospice and palliative care (Connor). In 1969, Dr. Elisabeth Kubler-Ross published a book discussing an approach to the care of dying individuals that included “respect, openness, and honest communication” (Loscalzo). She recognized the need to listen to the needs of patients in their final stages of life and driving care based on this. In 1973, the United States hosted its first Hospice center located in Connecticut (Connor). While the concepts were in play for centuries, the actual term palliative care was coined in 1974 by Dr. Balfour Mount as a means to avoid the negativity often surrounding hospice care. He focused on a holistic approach to patient care which included “physical, psychological, social, or spiritual distress”’ (Loscalzo). Furthermore, he delineated between hospice care by concentrating on individuals with “chronic or life-limiting diseases” (Loscalzo). While palliative care and hospice are two separate focuses, their historical foundations often go hand in hand. It is therefore important to note that the National Hospice Organization formed in 1978 after a series of national meetings (Connor, 2007). This organization would later become the National Hospice and Palliative Care Organization (Connor).

In the late 1970s to early 1980s the Center for Medicaid and Medicare Services (known then as the Health Care Finance Administration) initiated a project that studied the efficacy of hospice care in the United States (Connor, 2007). This was significant as the findings led to the creation of the Hospice Medicare Benefit in 1982 (Connor). This benefit was aimed at providing reimbursement for hospice care providers, however the initial benefit was only provisional and did not become permanent until 1985 (Connor)

Jumping forward to 1997, we saw the release of a report from the Institute of Medicine titled “Approaching Death: Improving Care at the End of Life” (Field & Cassel, 1997). This document recognized the inadequate state of end of life and palliative care management in the United States health care system, primarily with the advent of ever developing technology designed to delay the onset of death (Field & Cassel). Other key stakeholders and advocates around the same time included the Robert Wood Johnson Foundation and the George Soros’ Open Society institute (Loscalzo, 2016). These key players promoted the transition of palliative care from obscure to mainstream (Loscalzo).

By 2004, the National Consensus Project for Quality Palliative Care produced a set of guidelines for palliative care (Loscalzo, 2016). These guidelines continued to outline the care provided by palliative care in addition to further delineating between hospice and palliative care (Loscalzo). All of these movements led to a significant increase in palliative care programs from 632 in 2000 to 1,240 in 2006 (Connor, 2007).

The specialty continued to advance when in 2006 the American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education officially recognized the medical sub-specialty of “Hospice and Palliative Medicine” (Loscalzo, 2016). At this point in the historical timeline, there were already 57 fellowship programs nationwide that focused on palliative medicine. In 2008, the American Board of Medical Specialties gave their first certification examination in palliative medicine (Loscalzo).

Transitioning back into current events, the primary issues still thwarting the progress of palliative care include the need for training for health care professionals, national policies, and availability of adequate pain management (Lucas, N.D.).

Photo Credit

Header photo: http://www.stjh.org.uk/about-us/our-history


Connor, S. R. (2007). Development of hospice and palliative care in the United States. OMEGA, 56(1), 89-99. doi: 10.2190/OM.56.1.h

Field, M. J., & Cassel, C. K. (1997). Approaching death: Improving care at the end of life. Washington, D.C.: National Academy Press

Loscalzo, M. J. (2016). Palliative care: An historical perspective. American Society of Hematology Education Book, 2008(1), 465. doi: 10.1182/asheducation-2008.1.465

Lucas, S. (N.D.). Palliative care: Issues and challenges. Retrieved from http://www.who.int/3by5/en/palliativecare_en.pdf

Palliative Care Council South Australia. (2012). History of palliative care. Retrieved from http://www.pallcare.asn.au/about/history-of-palliative-care