___________________________________________ Palliative Care and Pain Management at the End of Life
skills training for nurses, and educational programs for home care professionals, as well national certifications [6; 74]. More than 18,000 nurses are Board-certified in hospice and pallia- tive nursing [75]. Reimbursement Policies Medicare reimbursement for hospice care became available when the Medicare Hospice Benefit was established in 1982, and reimbursement through private health insurances soon followed [34]. Reimbursement for hospice enabled more people with life-limiting disease to receive palliative care at home and in hospice units: the number of hospices in the United States has increased steadily, from 158 Medicare-certified hospices in 1985 to 4,639 in 2018 [1]. Despite the positive impact of the Medicare Hospice Benefit, fewer than half of eligible Medicare beneficiaries use hospice care and most only for a short period of time. This is because Medicare beneficiaries are required to forgo Medicare payment for care related to their terminal con- dition in order to receive access to Medicare hospice services ( Table 4 ) [34; 85]. The eligibility requirements of the benefit explicitly state that the focus of hospice “is on caring, not on curing,” and in order to receive reimbursement for hospice services, patients must sign a statement that they will forego curative treatment [34]. This requirement frightens some patients or their families, who subsequently view hospice as “giving up.” Furthermore, the restriction does not account for palliative treatments that serve the dual purpose of alleviat- ing symptoms while prolonging life. For example, therapeutic regimens and measures designed to optimally treat heart failure are the same as those used for palliative care of patients with heart failure [76]. At present, there are no Medicare regula- tions that specify which treatments are considered palliative, and this lack of clarity has led to variation in what treatments
within the American Board of Medical Specialties. The first exam was held in 2008, and 1,274 physicians earned certi- fication in hospice and palliative medicine. Since then, the number of physicians who have earned certification though the American Board of Medical Specialties has increased five- fold, with physicians in internal medicine and family medicine accounting for 85% of the total ( Table 3 ) [73]. Initiatives to enhance the knowledge and skills of nurses have included graduate nursing programs in palliative care, instructional resources for nursing educators, communication NUMBER OF PHYSICIANS CERTIFIED IN SUBSPECIALTY OF HOSPICE AND PALLIATIVE MEDICINE, 2014–2023 American Board Specialty No. of Physicians Internal medicine 4,167 Family medicine 1,573 Pediatrics 268 Anesthesiology 100 Emergency medicine 247 Psychiatry and neurology 119 Surgery 70 Radiology 60 Obstetrics and gynecology 71 Physical medicine and rehabilitation 29 Total 6,604 Source: [73] Table 3
MEDICARE HOSPICE BENEFIT
Variables
Criteria
Benefits (covered services)
Services of physicians; nurses; social workers; dietary counselors; physical, occupational, language, and speech therapists; hospice aides and homemakers; grief and loss counselors Medications for symptom control (small co-payment may be necessary) Medical equipment and supplies Short-term inpatient or respite care (small co-payment may be necessary) Care in an emergency department or inpatient facility, or ambulance transportation, unless arranged by hospice medical team Care from a provider not arranged by the hospice medical team Room and board Prescription drugs, other than for pain relief or symptom control Curative treatment
Nonreimbursable services
Period of care Restrictions
Two 90-day periods, followed by unlimited number of 60-day periods
Signed acknowledgment that treatment (including medications) directed at curing the terminal disease cannot be carried out Certification by physician at the beginning of each period of stay that the prognosis is six months or less
Source: [34]
Table 4
11
MDCA1525
Powered by FlippingBook