The major health care reform bill passed by Congress and signed into law by President Obama in 2010 originally contained a provision that would use Medicare funds to reimburse physicians for discussing end-of-life care options with patients during an "annual wellness visit."
Last week, the White House eliminated that provision from the reform in a move that received very little comment or attention. One hospice director, however, in Gainesville, Florida is concerned about not only this elimination, but the lack of priority given to end-of-life hospice and palliative care within the reform and in the larger context of American medicine.
He told the Gainesville Sun, "Health care reform is going to mean more regulation and less reimbursement."
The Obama administration's inexplicable decision to remove the provision is particularly disappointing because the pre-existing system that exists to give patients knowledge and options for end-of-life hospice care is failing. Medicare requires doctors and health care providers to give patients a list of available hospice providers in their area. It is a good law, but one that is rarely practiced and even more rarely enforced. Many hospice directors develop less-than-ethical relationships with health care providers, and these relationships influence the providers to direct patients to them, rather than inform them on all available options.
Similar problems arise in the relationships between hospices and nursing homes. Medicaid pays 95 percent of room and board fees to qualified residents in nursing homes. The involved hospice organization bills medicaid for the services it provides and then reimburses the nursing home. Hospices often pay the entire remaining 5 percent in turn for possible referrals.
While the health care reform provision would not have addressed the possibility of fraudulent practices in the complicated relationships that exist between health care providers and hospice providers, along with those shared between nursing homes and hospice providers, it would have given doctors and patients an opportunity to have important discussions outside those systems. It would have enhanced the intimacy of the doctor-patient relationship, and encouraged people to have painful, but important conversations.
Future discourse on medical policy and health care reform must prioritize end-of-life care and hospice.
