Op-Ed: Obamacare and its impact on end-of-life care

End-of-life care is facing a very serious challenge from the Patient Protection and Affordable Care Act, popularly known as Obamacare. What will be affected and how the program could have to turn to the private sector.

There comes a point in every family’s life when a loved one reaches a stage of their life when they need a great deal of help. Age and infirmity take their toll on the most virulent of people and eventually loved ones and professionals have to step in and help older citizens to live the end of their lives with dignity and respect. Regardless of whether that care is provided by persons at home, or within a nursing home these are important decisions that need to be made on a variety of levels including financial. One of the saddest results of Medicare cuts is the direct affect it will have on Hospice care around the country, most especially in rural communities. A 2011 study found that the 2% cuts that have already been pushed through on Medicare reimbursement will decrease the overall profit margins from 4% in 2008 to a negative 11% by 2019. This data shows that over 66% of all hospice programs would be affected negatively by these same, seemingly small, cuts. And it gets worse. Hospice care for rural America, where it is most needed, will decrease in profit margins from 0% in 2008, to a negative sixteen percent (-16%) by the year 2019. J. Donald Schumacher the president and chief executive officer of The National Hospice and Palliative Care Association (NHPCO), which commissioned the study, had this to say

“This analysis confirms our worst fears. With the entire hospice community – rural and urban, large and small, community-based and multi-state – being hit by the same devastating slope downward, there is no way for patient access to not be negatively impacted.”

The Patient Protection and Affordable Care Act (ACA) of 2010, is set to add an additional 11.8% in cuts to Medicare payments to hospice care over the next ten years through the introduction of productivity adjustments which could be devastating for the availability of hospice care for Medicare and Medicaid beneficiaries who make up the majority of the patients who take advantage of hospice care. In fact more than 85% of revenue that comes into Hospice comes from Medicare or Medicaid, cuts to which will significantly impact the ability of many programs to offer services. Most hard hit will be some of the extra programs and particularly charity programs offered by organizations to the elderly. Hospice by the Bay CEO Sandra Lew wrote in an annual report for 2008-2009, adding that a reduction in services could arise from such cuts. “Most hospices will have to look at their services, especially any charity and other services that won’t be reimbursed,” she said. “We’ll have to look at that.”

In terms of real dollars the effects of these cuts are even starker, though hospice leaders are seeking further legislation to try and offset some of the deeper cuts. With today’s program, in place as is, the cuts would total a minimum, and possibly more, than $10 Billion. Even with legislation to blunt the effects, the cuts would total around $7.8 Billion. While simultaneously looking at cutting programs and slimming down their budget, which means less staff besides less services, hospice organizations around the country are going to have to augment their revenue and cash flow by increasing their fund raising activities and depending far more heavily on private organizations and donations to keep the programs, which they are already offering, alive. Meanwhile the as part of the Patient Protection and Affordable Care Act, there would be a serious focus on reforming the payments made to hospice programs under which the Secretary uses data collected through 2011 to implement reforms. In other words the Secretary would implement revisions to the methodology for determining the payment rates for routine home care and other services included in hospice care no earlier than FY 2013. Once the program gets to 2013 each patient who is scheduled o get hospice care would need to meet with a hospice nurse practitioner in a face to face meeting. During this meeting the hospice care practitioner would need to determine if the patient was still eligible to receive hospice care. This would need to take place prior to the 180 recertification and also before each recertification. The practitioner would also need sign off on the fact that this meeting had taken place. Alarmingly the Secretary would then review “certain” patients in hospice with a high percentage of this focus being long term patients. In other words a secretary, appointed by the government, would be the final word in the continuation of health care benefits like hospice for the elderly. The plan adds an additional Independent Payment Advisory Board, which would be tasked with presenting Congress, with a series of comprehensive measures to reduce payments, excess growth in costs, and ways to “improve” the quality of care provided to Medicare recipients. Beginning in 2020, the bill will have this board make binding biennial recommendations to Congress in the, very likely, event that growth in overall health spending is greater than that of Medicare itself. The Secretary has been given the authority to test value based purchasing programs for long term care providers by 2016. This will include hospice and other providers. The NHPCO has announced that it will continue to fight and seek legislative measures to blunt or reduce these cuts and measures altogether because it understands that end of life programs can simply not afford to lose billions of dollars and still remain viable, and affordable. Hiring of employees is one of the key measures that will suffer under these cuts. Fedelta Care Solutions, a Washington Based Home Hospice Provider believes that the key to providing great hospice care is the quality of people that are hired. This is mirrored by an anonymous quote on Fedelta’s website by a client, whose parent cared for by the company "It was truly awesome that the caregivers were so well matched to my parent's needs - both medical and personal aspects."

Families everywhere are already struggling with the cost of providing medical insurance for their families and dealing with the rising cost of living. End of life, is a very emotional time that is already extremely stress filled. Families should not have to struggle to deal with the rising costs due to Medicare cuts, nor should those who have reached the end of their life have to sacrifice on the type and quality of care they receive because of the irresponsibility of other people. Companies like Fedelta are out there, providing the best care in the industry. It is up to use to make sure that Medicare continues to be funded so that it can continue to fund programs caring for our seniors at the end of their life. This is the least we can expect from ourselves, our government, and our political leaders.