holding handsRonald Crossno recently published an opinion piece in the Austin American Statesman (8-28-13) about several bills in Congress aimed at increasing the number of healthcare professionals trained to provide hospice services. The bills are: Palliative Care and Hospice Education and Training Act (H.R. 1339 and S. 641) and Patient Centered Quality Care for Life Act (H.R. 1666). These bills, if passed, would provide Federal support for training and various other activities aimed at increasing the availability of palliative care.

These are excellent initiatives and hospice is a most excellent concept. Let’s say that I agree with 98% of the purposes of these bills, but in the back of my mind is a question. One large goal of these bills, and by inference the healthcare providers who support them, is the expansion of specialty training for physicians and other service providers.

I think we do the overall effectiveness and affordability of healthcare a disservice by creating specialties where the specialty is focused on what, as is the case with palliative care, should be every healthcare providers concern.

I agree, we need highly specialist surgeons who can operate sophisticated robots to do delicate brain surgery on the small segment of the population who needs such skills. However, on the other hand, palliative care and hospice seem to be more in the category of what everybody needs to do as routine and integrated practice. I would rather see these two bills focusing on 1) undergraduate medical and other entry-level healthcare education and 2) the integration of palliative care into the basic mindset of all providers and consumers.

We tend to create these specialized training programs, that produce specialists, who then need a specialized center to offer the service. We then work for years to get insurance and government to pay for it, and in the end, spend twenty or thirty years maintaining this specialized structure that, perhaps, ever so slowly, diffuses into general practice. The end goal can get lost in the day-to-day. For example, hospice, developed by Dame Cicely Saunders in England in the 1960’s, is still not a part of everyday care, as evidenced by the existence of the two bills above, after half a century.

I realize there is a tradeoff when trying to make a new idea (hospice, for instance) common practice. One needs advocates and people skilled in the practices. However, creating specialties where the need is unwarranted just increases training costs, adds more bureaucracy to licensure, and creates specialized practice niches that add additional costs to the consumer.

I do think we need to have long range strategies when developing new ideas and methods that have as the end goal making services widely available, easily accessible and highly affordable. To date, we tend to do just the opposite.

Join us for a real-time discussion about the ideas raised by this essay on Tuesday from 12:00 p.m. to 12:45 p.m. See Discussion and SL tabs above for details. Link to the virtual meeting room: http://tinyurl.com/cjfx9ag.

Reference and Resources

  1. Crossno, R. Congress can improve patients’ quality of life. Austin American Statesman, Editorial, Aug. 28, 2013. http://www.mystatesman.com/news/news/opinion/crossno-congress-can-improve-patients-quality-of-l/nZcmh
  2. American Academy of Hospice and Palliative Medicine.
    Ronald Crossno’s blog at the AAHPM: http://www.aahpm.org/apps/blog/?author=165
    Academy web site: http://www.aahpm.org
    Consumer web site: http://www.palliativedoctors.org
  3. History of Hospice, National Hospice Foundation web site:   http://www.nationalhospicefoundation.org/i4a/pages/index.cfm?pageid=218

Image Source: http://www.stlouis.va.gov/services/Palliative_Care.asp

Hospice is a great idea. Developed in England over 50 years ago and a part of Medicare for the last 30 years, it has become an accepted part of end-of-life care. At first hospice was offered through non-profit services and mostly at home. Now a great deal of hospice care is offered by for profit corporations and in long term care facilities. The for-profit hospice services appear to have been “gaming the Medicare system” to maximize profits. The development of for profit businesses that exist to exploit aspects of Medicare and other insurance has a long history; remember in-patient youth psychiatric facilities in the 80’s and early 90’s? (Baughman, 1998; Gale Group, 2011)

Kenen (2011) discusses how the Department of Health and Human Services is seeking to cut back Medicare payments for hospice services. Hospice has grown into big business. Kenen states, “According to a June 2011 MedPAC report, the number of people getting Medicare hospice care doubled from 2000 to 2009, to more than 1 million, or about 40 percent of deaths. Total payments quadrupled, from less than $3 billion in 2000 to $12 billion in 2009. … Now, about half of hospices are for profit. Some are small, locally owned businesses, but much of the recent growth has been in big, publicly traded national chains, one of which is owned by the company once known as Roto-Rooter.”

Several strategies for reducing the costs have been suggested. Kenen says, “In 2009, MedPAC recommended that Congress scrap the standard payment rate, now about $151 per day, and replace it with a ‘U’ shaped scale. Hospices would get paid more at the beginning and at the end, when they typically provide the most hands-on care. In between, the daily rate would drop. Any hospice with a very high rate of long-stay patients would face additional regulatory scrutiny. A second approach, included in a recent MedPAC blueprint for offsetting Medicare doctor fees, would be to pay hospices a lower rate for nursing home care — 6 percent less, or about $3 billion in reductions over 10 years.”

Frankly these suggestions are rearranging the deck chairs on the Titanic. Health care policy in the US is rife with micro-management of services and costs that simply rearranges the status quo.

Why not rethink the whole thing? Go back to the beginning. Hospice was developed to meet a need in end-of-life care to back off from intensive interventions and to allow the dying person to approach death in a mindful and pain free manner. Was not the intent that hospice as a model for end-of-life care should become the regular and customary way any health care system helps dying people? In other words, get rid of hospice as an entity and simply make these well proved methods regular practice. All dying people would receive palliative care appropriate to their needs and their  care providers would know how this was done and arrange for it.

By eliminating  hospice as a specialized service and by stopping specific payments for providing it, we eliminate those niche for profit businesses that exploit Medicare. Hospice becomes not a “special activity” but a routine part of a person’s life. Seems simpler somehow. What’s wrong with this idea?


Baughman, Fred A. The Fraud of ADHD – Psychiatric History Repeating Itself. February 13, 1998. http://www.psychbusters.net/index.php?option=com_content&task=view&id=16&Itemid=28

The Gale Group, Inc. Psychiatric Hospitals: Industry Report. 2011. http://business.highbeam.com/industry-reports/business/psychiatric-hospitals

Kenen, Joanne. Medicare eyes hospice savings. October 17, 2011. http://www.politico.com/news/stories/1011/66177.html