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Hospice

2003-10-01 09:00:00

Returning to regular care

ANSWER:  Patients under the care of a hospice program are terminally ill.   According to the Medicare guidelines, this means a patient can realistically expect death to occur within six months or less if the illness runs its normal course.  Medicare requires that this prognosis be made by the patient's attending physician.  A second physician is asked to certify this assessment of a terminal prognosis; this second physician generally is the hospice program's medical director.   What about a patient whose disease process (whatever it may be; hospice cares for ALL patients with a terminal prognosis, not just those with cancer) is in remission or is not advancing?   Hospice programs are required to make assessments of the patient's condition on a regular basis.  If it is determined that the patient's disease is in remission, then the hospice program is required to dismiss that patient.  Medicare makes it very clear that only terminal patients be allowed to access the Medicare Hospice Benefit for reimbursement.   Upon revocation of the Medicare Hospice Benefit, the patient returns to regular Medicare coverage.   If it is determined later that the disease has returned and the patient is again considered terminal, then the patient can reelect the Medicare Hospice Benefit as the source of reimbursement for his/her care. As with the initial admission, and with this readmission, the terminal prognosis must be certified by a physician.   In addition to the above scenario, any patient can voluntarily choose to opt out of hospice (where the emphasis is on comfort care) and pursue curative care by signing a form.  While under curative medical intervention, the patient's reimbursement source will be through the regular coverage provided by Medicare for those who are eligible for this program.   Obviously, many are not eligible for Medicare or Medicaid, and have their medical costs covered through other insurance.  Many of these insurance companies follow the Medicare guidelines.  Therefore, the reimbursement scenarios outlined above apply for these companies.   The more difficult question in all this is determining when it is appropriate to pursue curative intervention and when it is more beneficial to come under the care of a hospice program.  Every human being wants to live as long as possible.  But as I posed in an earlier article for the Q & A Times, we need to honestly ask ourselves what is more important: how long we live or how we live long?   Of course, we would want to have aggressive curative treatment when there are "signs of recovery," meaning that the possibility of attaining a beneficial outcome from these treatments is realistic. But what if that is not the case?   What if the medical intervention, no matter how sophisticated, cannot realistically attain this?  What if the side effects from the treatment are especially severe?  These are difficult questions that deserve an honest answer.         The toughest question to resolve is, "When is enough enough?"  One way to answer this question is to ask, "Is the aggressive medical intervention doing something for us; or is it doing something to us?"   If the latter is the case (doing "to" us) then hospice is the better avenue to pursue.  The limited time left for living life is precious.  How will it be lived most fully:   pursuing aggressive medical interventions that can rob us of the energy needed to live this time well; or aggressive palliative (comfort) care that makes it possible to live life as fully as possible to the last minute?