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The New Health Dialogue

A Blog from New America's Health Policy Program

COST: Barring Poor People from Hospice is Not Smart (or Compassionate) Medicaid Policy

Published:  February 23, 2010
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We know states are struggling to find health care savings. But cutting hospice care for poor people on Medicaid doesn’t seem like a good place to start.

Arizona earlier this month moved to cut hospice benefits from its Medicaid program. Actually, it was going to go a step further and cut it retroactively -- making hospices repay the state for services it provided to dying people a year earlier. (This would apply to acute care patients, not those Medicaid patients in nursing homes, but that’s a whole separate story). Older patients, on Medicare, would still get access to hospice.

Where will dying people end up if they can’t get hospice at home? Many, needing pain and symptom management, will end up in hospitals, and in the expensive test-ordering, machine-utilizing parts of hospitals, ERs and ICUs. That will cost a lot more than the $140 or so a day that hospice typically costs in Arizona.

"Typically in the hospice world, individuals are not seeking aggressive treatment anymore; they are seeking comfort care," Agnes Poore, chief clinical officer and co-founder of Casa de la Luz Hospice told the Arizona Star. "But typically in the hospital, they might do diagnostic tests. If you need pain management, they might admit you to the hospital. Emergency room and hospital costs are enormous compared to what you would pay for hospice care."

This story burst into the Arizona newspapers a few weeks ago but we got sidetracked by the blizzard(s) and other things. So to find out where things stand, we spoke today to Judi Lund Person, a vice president at the National Hospice and Palliative Care Organization who tracks state developments. She said it isn’t clear whether the Arizona cost-cutters really intended to cut Medicaid hospice or whether they accidentally left out hospice in a list of covered services. At the moment, the status of the Medicaid benefit (and the reimbursement) is unresolved.

At first we were relieved -- maybe this was just a bureaucratic snafu, not a trend. Our relief was short-lived. Arizona may or may not have targeted hospice for Medicaid cuts, but Lund Person told us at least a half-dozen other states are seriously considering it, or had recently considered it. Cutting access to hospice, for people who choose to use it, makes no fiscal sense. It is also a setback for the long drive to get high quality end of life care to all who need it. Medicare created a hospice benefit in 1982. Medicaid took a slower state by state path, but as of now, 49 states (Oklahoma is the exception) offer Medicaid hospice. We certainly hope it stays that way.

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