One of the reasons I have not been writing a great deal recently, is because I have been working on the paper due in my health policy class. It is a group paper, and the subject is, unsurprisingly, End-of-Life Care Policy, with my portion of the paper/project focused upon hospice.

What I find so disturbing about all this is not that the US lacks a cohesive end of life care policy, because that isn’t it. Yes, there are issues such as euthanasia that have yet to be resolved, but that is only a minor issue in the grand scheme of end-of-life care. What surprise me is that despite the existence of relatively strong policy, so very little has been achieved.

In the United States, hospice is covered by most private insurance companies, as well as by Medicare Part A. The Medicare Hospice Benefit is quite generous, and one assume (perhaps incorrectly I admit) that private insurance coverage would be similar. For instance, Medicare covers: doctor services, nursing care, medical equipment and supplies, drugs for symptom control and pain relief, short-term hospital care including respite care, home health aides and homemaker services, and grief and loss counseling for both the patient and the family. The Medicare hospice benefit was created to make things as easy for patients and their families as possible. Patients pay no more than $5 for their prescription drugs, and 5% of the cost of any respite care they receive.

So, you’re thinking, the benefit is too generous and costly, and that’s why it is under-used! You would be wrong.

Palliative care (emphasized by hospice) can can improve patient quality of life, and decrease costs. In one study palliative care decreased the number of days in intensive care by 75%. Nationally, in 1998 hospital inpatient charges were an average of $2177 per day, while hospice cost only and average of $113 per day. This means that Medicare not only improves the quality of life for dying patients, but reduces the cost of medical treatment. A win-win situation.

Despite this, hospice utilization remains low. Nationally, the average for the year 2000 was 48 days of hospice use per patient; the average in West Virginia was 52 days of hospice use per patient. Although patients are best served by a longer time in hospice, 79.6% of those who enroll in hospice used only one benefit period.

Hospice and palliative care increase patient quality of life, as well as decrease medical costs, yet it is under-utilized. Why is this?

The prime reason, in my opinion, comes down to how people feel about, and deal with, death.

In my personal experience, when a family member was diagnosed with cancer several years ago, despite urging, they did not want to discuss end-of-life care options, or what they wanted to happen to their body if they were to die. Luckily this turned out not to be an issue, as the treatment went well, but I think it does illustrate a common problem in the US, which is a seeming inability to deal rationally with death and age.

We in the US, as a society, glorify youth, health, and beauty, and try our best to ignore or hide signs of aging, illness, and death. Glance through magazines and catalogs. The models are nearly universally young, thin, and attractive. (However two exceptions to this rule are Land’s End and Gardener’s Supply. Both catalogs use older models.) Look at ads–it seems as if every pharmaceutical company out there is advertising products to make you act and feel younger. Not that I blame the companies really, I mean, if beautiful blondes sell product, then so be it, but have we as a society fallen for it hook, line, and sinker?

This is an issue, and one that is going to become increasingly more important as the baby boom generation retires and starts to realize that no, they will not be young forever.

The other realization, and one that deals with the topic at hand, is that few want to admit they are going to die, and hospice is a tacit statement that death will come, and it will come faster than we want. Yet denying that truth does not make it go away, it only makes the end and the passing harder to bear.

WV Center for End-of-Life Care
Hospice Association of America
Hospice Foundation of America
National Hospice and Palliative Care Organization
Centers for Medicare and Medicaid Services
AgingStats.gov