For many years, Medicare has covered palliative or non-curative care at the end of life through its hospice benefit. The benefit is intended to allow people, with six months or less to live to die peacefully in their homes rather than in an institution. But, as Alexis Drutchas et al. describe in Health Affairs, the Medicare hospice benefit has become a luxury because only a privileged few can arrange for all the requisite at-home care that Medicare does not pay for under the hospice benefit.
A large portion of older adults and people with disabilities cannot afford to take advantage of the Medicare hospice benefit and are forced to die in hospital or in a nursing home. They do not have friends or family to care for them and they cannot afford to pay for the in-home caregiving they need in order to take advantage of the Medicare hospice benefit. Without family or friends to supplement the care that Medicare covers or the resources to pay for caregivers, Medicare hospice providers generally will not step in.
Medicare pays hospice providers about $203 a day to provide limited routine care to people at the end of life. And, it caps spending on hospice care to $31,297 a person. For this money, people can only receive a small amount of care from nurses and home-health aides. Hospice providers do not want to take on patients who are at risk living on their own without caregivers at home.
Talk to your doctor about your health care wishes at the end of life and, specifically, about the Medicare hospice benefit during your annual wellness visit, which Medicare covers. If you might be interested in hospice, find out whether there’s a hospice in your community that you would want to use. Keep in mind that one in five hospices suffer from severe deficiencies.
Be aware that for-profit hospice agencies might be very different from non-profit agencies. Two in three hospice agencies are now for-profit, owned by private equity and public companies. They might step in to provide hospice, such as addressing pain or helping with activities of daily living, but not to deliver the rich array of at-home benefits people need at the end of life. And, data on average hours agencies spend delivering care are not easily accessible.
Hospice patients often get just 30 minutes of care each day or three and a half hours a week. Thirty minutes a day is not enough to assist people with even the simplest of needs, such as help taking medicines, going to the bathroom and bathing,
Medicare is now spending an average of $80,000 on individuals in the last year of life. It spends whatever amount necessary for curative treatments and treatments for people with chronic conditions, even if there is no hope of a person’s survival. But, it limits spending for palliative care at home for people at the end of life.
To serve the needs of people with disabilities and older adults, Medicare should not put tight constraints on what it spends for hospice care at home. And, it must insist on collecting data on the amount of time hospice agencies spend with patients and how, more broadly, these hospice agencies spend the money Medicare pays them.
When choosing a hospice, people should know how many hours of care a particular agency provides from nurses and home health aides. Hospice Compare, the Medicare hospice comparison tool, does not provide this information.
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