



Have a life expectancy of 6 months or less if the illness runs its normal course

Sign a statement choosing hospice care instead of routine Medicare covered benefits {i.e. curative care} for their terminal illness.

Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is based on the beneficiary’s need for skilled care.

Defining hospice eligibility relative to the 6-month prognosis mark is clinically arbitrary and practically difficult, especially for people with non-cancer diagnoses.

Limiting hospice to patients who disavow disease-modifying therapy enforces an artificial distinction between curative and palliative therapy and potentially impedes both enrollment and quality of care.

Carving out hospice from other Medicare services reinforces the notion that such care falls outside the core competencies expected of providers such as nursing homes and Medicare Advantage plans and conflicts with efforts to integrate care and align incentives across providers and settings.

Policies should aim to integrate timely, high-quality palliative and end-of-life care into the continuum of services that {Medicare} beneficiaries receive.

Integration of hospice into care delivered by Medicare Advantage plans, by accountable care organizations, and under bundled payment models more broadly, would allow for beneficial hospice and palliative care services to be introduced at any point in patients' care, regardless of their prognosis.

This approach could ensure greater continuity of care and would be consistent with the broader aim of reorienting Medicare toward the delivery of flexible, patient-centered care driven by patients' needs rather than by narrow and potentially inefficient eligibility and payment policies.

Access to hospice care is still constrained by the eligibility requirements that patients have a prognosis of 6 months or less without life-sustaining treatment and they forgo life-sustaining treatment related to their hospice admitting diagnosis.

These criteria create delays in hospice enrollment.

The hospice benefit does not include a test of needs and relies instead on the requirement that a patient’s preferences are consistent with comfort care. Prognosis and preferences are only indirect indicators of need and many patients with substantial needs for hospice services have a prognosis or treatment preferences that make them ineligible.

By now most everyone has heard about theof athat would do away with the requirement to show a likelihood of medical or functional improvement before Medicare would pay for skilled services such as physical therapy.This has led me to wonder if it is time toThe case for the Medicare skilled nursing benefit lawsuit ( according to the New York Times ):I foundfor a case against the current Medicare Hospice Benefit eligibility requirements in thearticle “ Growing Pains for the Medicare Hospice Benefit ” published this week:I foundto build a case against the current hospice eligibility requirements in the 2011 JAMA commentary “ Rethinking Hospice Eligibility Criteria ”:And for those concerned about theof allowing more people to receive the Medicare Hospice Benefit:I have decided that there is compelling evidence that the Medicare Hospice eligibility requirements are outdated and need to be re-written. These policies areand the evidence is mounting that limiting access to hospice and palliative services actually increases the cost of health care at the end of life. Those with concerns about the rise in the cost of the Medicare Hospice Benefit appear to put undue focus on the increasing length of stay of a number of hospice patients without considering that hospice and palliative care can be more cost effective than usual care. This cost reduction does not come from "irrationally rationing" health care but by facilitating conversations that allow patients and families to understand prognosis and verbalize preferences and goals about end-of-life care. These conversations enable health care providers to guide patients away from costly treatments and interventions that do not facilitate attainment of patients' goals or add to the quality or length of their lives.If you agree that it is time for a change to the eligibility requirements, what can we do as hospice and palliative medicine providers to advocate for our patients to receive high-quality palliative and end-of-life care in a manner that makes sense?Do we wait until the results of the concurrent care demonstration project are in? Do we ask AAHPM, NHPCO, and HPNA's Public Policy and Advocacy Committees to weigh in on the matter? Or do we wait until the lawyers file another class-action lawsuit against Medicare?by: Shaida Talebreza Brandon (all opinions expressed are my own)