Gov. Matt Blunt’s proposed cuts in Medicaid services include the elimination of hospice benefits, a move that hospice providers say will actually cost the state additional money.
Blunt’s spokesman Spence Jackson said that the state must get a handle on social service spending if it is to preserve most of the social programs that people have come to expect.
“Certainly we realize that this is a good program and has helped people,” Jackson said. “However, we are at a point in our budget where difficult choices are needed. The budget Gov. Blunt has submitted is one that does not spend more money than the state takes in.”
Jackson pointed out that social welfare is not the only target of budget cuts. Blunt recently made additional cuts of $240 million by redirecting money from nearly every state budget, Jackson said.
However, Fred McDaniel, executive director of the not-for-profit HospiceCare, Inc. in Park Hills, said that cutting the benefits would not be a sound fiscal move.
“The state is not going to save money by cutting the hospice benefit,” McDaniel said. “In 1985, the state put the hospice benefit into the Medicaid plan because hospice service costs less per patient than hospital care.”
The budgetary future of Missouri’s Medicaid hospice benefit remains uncertain.
Senate Bill 539, which would allow legislators to make cuts in Medicaid services, eliminated hospice and other optional programs. However, the House Appropriations Committee recommended the program be fully funded. Funding estimates for continued hospice services under Medicaid range from approximately $5.1 million to $5.4 million annually.
However, members of the House of Representatives and the Senate must approve the bill and Blunt must sign it for that recommendation to take effect.
Dying at home
Hospice is a medically directed, team-oriented program of care for terminally ill patients and their families. To qualify for hospice, a patient must be diagnosed as having six months or less to live, given the typical course of the illness if left untreated. Patients also must have decided not to pursue aggressive treatment.
Approximately 20,929 terminally ill patients were serviced by Hospice organizations in Missouri in 2003, according to Missouri Hospice and Palliative Care Association statistics. Of those, 1,035 were Medicaid patients.
HospiceCare Inc. is the only not-for-profit hospice company that services St. Francois, Ste. Genevieve, Madison, Iron, Perry and Washington counties, along with sections of Reynolds and Jefferson counties, said Tammy Bracken, director of public relations for the company.
More than half of the HospiceCare Inc. hospice patients have cancer, McDaniel said. Approximately 90 percent are covered under Medicare, with another 6 percent or so covered under Medicaid. Approximately 2 percent of the clients have no insurance, and the remainder use private insurance to cover the hospice services.
“There’s a bad attitude in our society about people on Medicaid,” he said. “Many people can’t work when they get sick, so they lose their job and insurance. They can’t afford the high COBRA payments to keep insurance, so they are forced to go on Medicaid. These are the people who are hurt by this.”
Hospice teams work with the entire family throughout the last months of a client’s life. The Hospice care usually is provided in the patient’s home. Its goals are to manage pain and control symptoms, and its focus is on comfort and quality of life rather than curing or prolonging life. Hospice teams typically include a doctor, nurse, social worker, clergy, bereavement counselors, volunteers and aides, and are available 24 hours a day to care for the patient and provide support for family members. They continue to support family members who struggle with grief after the death of their loved one.
“We were afraid it would be an invasion of our private life,” said Kathryn Green, whose husband Darrell asked for hospice several months before his death in November. “That’s not the way it was at all. It was just like having someone come along and say ‘Let me help you with this, because it’s heavy.'”
Although the Greens did not need Medicaid coverage, Green said it is important for the state to provide that benefit. Hospice allowed her beloved husband to die at home in familiar surroundings, with constant companionship of his family and consistent care by a hospice team who stayed until the end, she said. That would not have happened in a hospital, Green believes.
“In a hospital, he would be surrounded by people who didn’t know him and who he might not see again,” she explained. “At home I was with him and I knew what he needed. I could help him turn, or rub his back. I have precious memories from eating breakfast together and being with him during those months. I never would have had them if he had died in the hospital.”
Reducing medical costs
Hospice teams provide medical care, keep patients’ pain in check and buy their medicine and equipment – all for a flat fee, McDaniel said. Without hospice, dying patients would still need services such as ambulance transportation, emergency room treatment, hospitalization, intensive care, and medication. Those services would cost the state through Medicaid, he added.
Spokesmen from Parkland Health Center and Mineral Area Hospital confirmed that if patients who are not under hospice care are brought to their hospitals, the hospital must provide emergency care and perform lifesaving or life-extending procedures unless the patient or patient’s representative deems otherwise.
“If someone comes in who is having trouble breathing, for example, we might have to drain fluids to help the person breathe,” said Joe Easter, director of nursing at Mineral Area Regional Medical Center. “We have people here with living wills who don’t want anything done, but that’s up to the patient.”
According to information from the Missouri Hospice and Palliative Care Association, hospice care became an option under the Medicaid program in 1985 and 47 states have added it to their programs. Missouri’s Medicaid Hospice Benefit pays a flat fee of approximately $120 per day per patient. Hospice care keeps Medicaid patients from dying in a hospital ICU/CCU room, which costs regular Medicaid more than $2,000 per day. Most hospice prescriptions are covered under the flat fee, and otherwise would be an additional cost to Medicaid. Hospice patients do not receive chemotherapy or radiation treatments and emergency room services that are customary under regular Medicaid. Hospice patients also are less likely to have ambulance trips.
According to projections in the Milliman and Roberts Report, a document that the Missouri Hospice and Palliative Care Association cites, additional cost to the state if the hospice program did not exist would be in the millions and would increase annually.
Researchers for the report assumed an annual increase of 3 percent in expenses and 10 percent in the number of hospice patients when calculating additional costs. Based on that formula, Missouri would have spent an additional $6,967,620 for hospitalization and pharmacy costs in 2003 if it had not had the hospice program in place. That estimate was $7,696,294 in 2004.
Jackson criticized the report, calling the figures speculative.
We don’t know the details of every patient’s situation,” he said. “However, we have received reports from across the state that there are individuals who are using benefits who have other resources.”
State Rep. Brad Robinson, D-Bonne Terre, agrees that fraudulent claims must be eliminated, but said that shouldn’t mean cutting out an entire program.
Meeting emotional needs
Budgetary concerns mean little to a person who is dying. Patients often are far more concerned about the need to appear strong before their families. Still, they need someone to talk with about their concerns, said Ralph Burris, a Hospice chaplain for seven years.
“There’s something about dying that you want someone to hold your hand and pray with you,” Burris said. “They’re so thankful that Hospice is there.”
Rep. Steven Tilley, R-Perryville, said he believes that cuts are necessary, but that he believes hospice is one of the last programs he would support cutting. Tilley wrote of his experience with hospice in a letter he wrote to Pam Shell, HospiceCare Inc. director of nursing.
“I have just had two family members pass away from cancer,” Tilley wrote. “They both needed hospice care. This provided our loved ones to be able to spend their last moments as pain free as possible … I will work hard to ensure that this service remains funded.”
Darrell Green’s hospice team, consisted of Burris, nurse Donna Spain and social worker Laurie Willmore. The team not only helped Green deal with her husband’s failing health, they encouraged her daughters to make a scrapbook of memorable moments. The team also helped the couple’s grandchildren to deal with his impending death.
Green was so impressed with the support she and her husband received from hospice, she now volunteers for HospiceCare Inc. in Darrell’s memory.
“I hope they don’t cut hospice,” Green said. “To take away hospice benefits is like kicking someone when they are down.”