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Howard Tuch

Cut in Medicaid hospice benefit wrong, costly

Starting Monday, state lawmakers meet to find ways to resolve Florida's looming budget deficit. Difficult choices await as the Legislature searches for ways to cut an estimated $2.3-billion from this year's budget. One of the cuts being considered — eliminating the Medicaid benefit that provides hospice — could actually end up costing the state more than it currently spends. Patients denied hospice will still need medical care, and many will end up in emergency rooms and expensive hospital beds at far greater cost to the state and to local providers.

Hospice provides care through a coordinated team of doctors, nurses, home health aides, therapists, social workers and chaplains to patients (and their families) with terminal illnesses. Nearly 1.4-million patients in the United States received hospice care last year. Research into hospice demonstrates substantial cost savings as patients and families receive the care and support they need to remain comfortable and at home throughout their illness. A recent Duke University study concluded that, on average, hospice saved Medicare $2,300 per patient compared to usual care. Surveys routinely reveal the high value and benefit families experience with hospice.

Medicare (and most privately insured) patients are eligible for hospice in the last six months of their lives. Medicaid, the joint federal-state program that covers care for many poor children and families, also includes a hospice benefit. Even though states are not required to provide hospice through their Medicaid programs, 48, including Florida, do so. In tough times, several states have considered, then rejected, the possibility of eliminating their Medicaid hospice benefit after lawmakers understood the potential for patient suffering and the cost savings involved. Each state dollar cut from the Medicaid program results in the loss of an additional $1.24 in federal funds. Together, $2.24 in goods and services is lost (think jobs for health care workers).

Hospice usually cares for patients in their own homes, whether that is a private home/apartment, assisted living center or nursing home. This past year Florida's hospices provided care for more than 7,600 patients and their families through the Medicaid program. In Pinellas County alone, the Hospice of the Florida Suncoast cared for more than 375 patients and families through the Medicaid benefit last year. These patients were on average younger than other hospice patients, most had cancer or AIDS diagnoses and about 80 percent lived in the community. Patients needing hospice often suffer from many illnesses and already experience limited access to specialty or coordinated care.

According to anew study commissioned by Florida Hospices and Palliative Care and conducted by the Washington-based Moran Co., Florida will actually increase its spending on care for the state's terminally ill if it eliminates its hospice benefit. The study concludes that most of the costs attributed to hospice would simply be shifted elsewhere in the Medicaid budget. The study estimates that the increased cost for Florida taxpayers would have been $3.7-million in 2007 if the Medicaid hospice benefit was not available — clearly, not the cost savings lawmakers hope to achieve with the proposed cut.

Medicaid or Medicare payment for hospice care is all-inclusive: Every home visit by nurses, home health aides, social workers, chaplains, physicians and community-based volunteers is covered by one daily fee. Patients and families are usually not charged for services. The hospice fee also covers prescription drugs, over-the-counter medications, medical equipment and medical supplies associated with the patient's primary diagnosis. Family members receive support from chaplains and social workers, and bereavement care can last more than a year after a death. Hospice provides care regardless of a patient's insurance status or ability to pay. Medicaid cuts added to Medicare payment cuts already enacted will place huge demands on dwindling resources. The Hospice of the Florida Suncoast provided $11.7-million in unreimbursed care last year.

Hospice care should be a choice available to all Floridians. To deny hospice to impoverished and dying patients, knowing that greater suffering will result, is just wrong. To eliminate a benefit that has been shown to decrease health care costs at a time of fiscal crisis is just foolish. This week our legislators will have to make many painful choices. We hope that they will have the knowledge and wisdom to make the best choices for all of us. Eliminating hospice care for Medicaid patients is not one of the choices they should make.

Dr. Howard Tuch is the Robert Woods Johnson Health Policy Fellow with the Hospice of the Florida Suncoast. He has worked as a hospice and palliative medicine physician in Florida since 1992.

Cut in Medicaid hospice benefit wrong, costly 01/03/09 [Last modified: Thursday, January 8, 2009 7:24pm]

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