First the ICU, then Hospice

Award Year:
Joan Teno
End of Life Care
In 1982, Senator John Heinz introduced an amendment as part of the Tax Equity and Fiscal Responsibility Act that added hospice coverage to Medicare beneficiaries. Innovations in Medicare usually focus on payment, not on creating a new benefit. This amendment defined a new benefit with the goal of being cost neutral or reducing the cost of end of life care. Hospice is now part of mainstream medicine and hospital based palliative care teams are part of 80% of hospitals with more than 300 beds. Yet our study published in the February 8, 2013 issue of JAMA found more ICU care, more repeat hospitalizations in the last 90 days of life, and more patient transfers from acute care hospitals to another health care setting in the last three days of life. An overarching goal of this project is to examine these perplexing findings and to ask fundamental questions from a broad perspective on the role of hospice and palliative care teams in our evolving health care system that is bundling payments in the form of Accountable Care Organizations and other programs. A mixed method approach will be used to triangulate in-depth interviews of multiple stakeholders with secondary analysis of Medicare billing data to understand the past and present, as well as envision a future that promotes patient and family centered medical care. The project also will examine publicly traded, hospice chains’ impact on the hospice landscape. Dying is a sentinel event with well-documented high costs and striking geographic variation. This three-year effort will produce several publications with associated opinion pieces that will reflect on hospice and palliative care teams’ roles in our evolving health care system.