Hospice costs a Vineyarder nothing
Hospice care is free from Hospice of Martha's Vineyard
By next year, residents of Martha's Vineyard will have a choice of two agencies that will provide complete hospice care on-Island, at no cost to the patient.
Hospice providers affirm the concept of palliative care as an intensive program to enhance comfort and promote the quality of life for individuals and their families. When cure is no longer possible, a peaceful and comfortable death is an essential goal of health care.
The hospice movement began in England in the 1960s, and the first American hospice opened in Connecticut in 1974. Hospice of Martha's Vineyard (HMV), certified as a hospice by the Massachusetts Department of Public Health (DPH), has provided hospice care to Vineyarders since 1982.
Supported entirely by donations, HMV provides care for persons in the last phases of an incurable disease so that they may live as fully and as comfortably as possible. It provides nursing and social services, as well as help from its many volunteers, who spend time with the patient and pitch in with ordinary tasks throughout the final months of a terminal illness, but only if requested by the client and the family. HMV also helps the family of the dying person with expert counseling and information, as well as with bereavement and spiritual support. HMV is on-call 24 hours a day, and often provides continuous presence in the final days. These services have always been completely free to the patient and his family.
Medicare Hospice Benefit
In the early 1980s, Congress created legislation establishing Medicare coverage for hospice care. The Medicare Hospice Benefit was made permanent in 1986.
To qualify, a Medicare-eligible patient must have a diagnosis of less than six months to live (if the patient outlives the diagnosis, the benefit may be extended). The only cost to the patient is the Medicare premiums the patient has paid. Under this benefit, Medicare pays for all palliative medical expenses, including doctor's visits, medications, speech, language, and occupational therapies, necessary medical equipment (such as a hospital bed, wheelchair, or walker), the services of a home health aide (to bathe the patient, for example), and inpatient respite care for caregivers. These medical expenses have not been provided by HMV, and patients or their insurers have had to cover them.
Until this spring HMV had made a deliberate choice to forego the Medicare Benefit in order to avoid Medicare's regulations. Patients (or their families) have often come to HMV in advance of the six-month time frame. More important, once a patient elects a Medicare Hospice Benefit, Medicare will no longer pay for aggressive treatments such as chemotherapy, radiation, dialysis, or surgery, which HMV clients often wanted to continue.
On May 28, however, HMV changed its long-standing policy and announced that eligible HMV clients can elect a Medicare benefit from Hospice and Palliative Care of Cape Cod (HPCCC). HMV changed because HPCCC has an "open door" policy. According to HMV executive director Terre Young, this means that while Medicare will not pay for continuing aggressive treatments, HPCCC will. She says that HMV will continue to offer the services it has provided since 1982, under the same terms, but it will now offer a Medicare Hospice Benefit as well without any limitation on treatments. When the time comes to elect the Medicare Benefit, clients will transition from HMV to Island Hospice, a joint venture with HPCCC, and continue to see the same nurses, social workers, and volunteers. HMV patients can continue to fight their disease at the same time they receive hospice care.
Ms. Young told The Times in a telephone interview that she expects that in the future HMV will help raise funds to allow HPCCC to continue its open door policy on Martha's Vineyard.
Vineyard Nursing Association
The Vineyard Nursing Association (VNA) has provided medical support services in patients' homes (nursing, therapists, social workers, etc.) since 1984. This winter VNA announced that it will add a Medicare-certified hospice benefit to its services, beginning in 2010.
VNA director of clinical services Sandie Corr-Dolby points out that VNA has been providing end-of-life services (but not DPH-certified hospice services) to Vineyard patients for 25 years - however, without some of the volunteer support and bereavement counseling offered by HMV. In 2008, of 81 VNA patients who were terminally ill, 21 elected to receive hospice support from HMV, and 60 decided to just continue with VNA, feeling comfortable with the caregivers they already knew. For those who would accept the "terminal" diagnosis, the Medicare hospice benefit would have provided complete care for the rest of their lives, without any additional insurance claims.
It is Ms. Corr-Dolby's hope that the VNA will soon be able to provide a seamless transition from regular medical care to free hospice care. VNA is also on-call 24 hours a day.
Robert Tonti, executive director, expects that VNA will be certified as a hospice program by the DPH in mid-September. Certification by Medicare will take longer - he hopes by the end of the year. "We already have the staff in place," he says. Beginning next year, VNA clients could receive the Medicare hospice benefit at no cost.
The programs cite the opportunity for aggressive treatment in different ways. Ms. Young says that HMV hospice care and aggressive treatment can operate simultaneously. Mr. Tonti says VNA hospice care and aggressive treatment will operate sequentially. He says that under the VNA plan, a Medicare hospice patient who wishes to pursue a promising treatment (chemotherapy or radiation) may opt out of the hospice program, receive treatment under standard Medicare, and then, if the treatment doesn't work, be recertified by a physician to return to the Medicare hospice program.
The national debate
In the national news this week, opponents of the health care reform bill now before the House of Representatives have focused on a provision which would allow Medicare or Medicaid to pay for consultations with a doctor about the patient's end-of-life wishes.
"This provision may start us down a treacherous path toward government-encouraged euthanasia if enacted into law," House Minority Leader John Boehner, R-Ohio, and Rep. Thaddeus McCotter, R-Mich. said in a statement last month.
On its web site, the National Hospice and Palliative Care Organization (NHPCO) weighed in this week on the attempt to link the advance care planning provision in the House's health care reform bill with euthanasia. In a press release, NHPCO wrote, "Uninformed individuals have described this provision as a mandatory session that would dictate health care choices for older Americans. This is inaccurate and has resulted in confusion surrounding the value of advance care planning. . . . This consultation, like other consultations within the Medicare system, would be voluntary."
President Obama said much the same thing in a press conference over the weekend.
Writing in the Boston Globe, columnist Ellen Goodman commented on end-of-life conversations. She wrote, "In a study of terminal cancer patients at the Dana-Farber Cancer Institute, those who had end-of-life conversations spent about one-third less in their last week than those who didn't. And they had a better quality of life and death. Yes, those who didn't talk about options had more aggressive treatment. They ended up in intensive care and/or on ventilators or were resuscitated. They not only had a worse quality of death by any measure, they left their families in more distress, and here's the kicker: They didn't live any longer."
In a meeting of hospice supporters at the West Tisbury Congregational Church last week, Dr. Donald Schmacher, president and CEO of NHPCO, claimed that 65 percent of Medicare Benefits are paid in the last year of life, and "80 percent of the 65 percent in the last month." While conceding that hard data is scarce, Dr. Schumacher asserted that billions of dollars are wasted on ineffective (and often cruel) heroic but unsuccessful attempts to prolong life. But despite the potential cost-saving benefits of the nation's 4,753 hospice providers, Dr. Schumacher does not suggest that hospice care should be mandatory or that the government should do more than provide a voluntary option.
Hospice will continue to be an option for Vineyarders facing a terminal diagnosis. And on the Vineyard, it's free.