Viewpoint: Labor-related reimbursement cuts aimed at hospice care should be rescinded without delay

August 1, 2008

Labor-related reimbursement cuts aimed at hospice care should be rescinded without delay

When you first meet your hospice patient and take her hand, she'll hold on tightly to you . . . months later, when you take her hand, you're the one holding on to her.

I learned that poignant truth during my training to be a certified hospice volunteer a couple of years ago. Volunteers - as well as a highly skilled team of doctors, nurses, and social workers - are of critical assistance to terminal patients as they struggle with their illnesses.

The nation's excellent hospice program, which has served more than 1.3 million patients in the past 25 years, according to the National Hospice and Palliative Care Organization in Alexandria, VA, is now facing severe Medicare cuts. These reductions are all the more poignant in light of the NHPCO estimate that more than a third of all deaths in the U.S. occur while patients are in a hospice program.

The Centers for Medicare and Medicaid Services says the current hospice reimbursement rate is based on an old, "artificially high" wage index. The Bush administration's proposed 2009 budget would eliminate the "budget neutrality adjustment factor" that has been applied to the labor portion of hospice payments for the last 11 years, effectively resulting in a 4 percent annual cut in hospice reimbursement rates.

In a twist on the "making lemonade from lemons" outlook, the administration says the cuts stem, at least in part, from the incredible success of the hospice program. The number of hospice providers has grown from 1,545 in 1980 to about 4,500 in 2006.

But in a time of increasing mobility, when people are less likely to live near family members and other loved ones, this may be the worst possible time to squeeze the hospice program.

During my volunteer training, one of the sessions focused on Elisabeth Kubler-Ross' now well-known stages of grief - denial, anger, bargaining, depression, and acceptance - that we experience when faced with impending death.

Some of the volunteers, all good-hearted men and women, were initially inclined to be a bit too eager to help guide hospice patients through the Kubler-Ross stages. Our hospice trainer gently admonished, "Not everyone goes through the entire grief cycle; some people get stuck in one stage. And you can't count on a moment of blissful transformation, like in a movie death scene. Some people who lived bitter, petty lives often die in the same spirit." It's a valuable reality check for some volunteers.

The patients I was assigned to were so end-stage, they died within weeks of my meeting them. One 64-year-old woman with advanced lung cancer became comatose the day after I arrived. Yet the volunteers' presence often comforted the families, who were experiencing their own stages of grief. They were relieved to be able to pour out their anguish to a sympathetic individual who knew how to listen and didn't offer platitudes.

As important as the volunteers are to the well-being of this excellent program, the physicians, nurses, caseworkers, and other clinicians are even more vital in making hospice a valuable place of passage for terminally ill patients.

That's why labor-related reimbursement cuts aimed at hospice are so short-sighted, and should be rescinded without delay.