Monday, February 16, 2009
(This is the last in a series of 5 posts (#5, #4, #3, #2) about issues in hospice & palliative medicine I think will be important in the next year. Feel free to disagree!)*
#1 The Economy's Effect on Hospice & Palliative Medicine
The economy is in the tank, people are losing health insurance when they lose their jobs, people are cutting back on accessing health care. With hospitals potentially seeing less patients and having to possibly cut back on services would palliative care consult teams be near the top of the list? By our own success we have been defined as cost-savers and quality-raisers both good things to a hospital administration, but when your team is not considered as a revenue center your ability to be let go becomes easier. Well maybe not you, the doctor, but maybe your admin support, or your chaplain, or your social worker gets 're-purposed' to case management. Pretty soon your palliative care team may be more of a palliative care duo.
For hospices things could swing many different ways. While recessions have been linked to worse public health and even higher mortality rates so the potential people requiring hospice services may grow. But if these patients do not have insurance and do not qualify for Medicare or Medicaid programs, hospices will find themselves with a higher proportion of charity care and some hospices may not be able to sustain a large shift in payor mix towards charity care. Also many not-for-profit hospices agencies rely on an investment endowment to cover some expenses and with the recent stock market drop (and Bernie Madoff) this could not have happened at a worse time. Publicly traded for-profit hospices (Odyssey and ChemMed/VITAS) may be affected as well with any global stock drop but both are near 52-week highs currently.
There is some silver lining for our field economically given the recent passing of the stimulus bill. The legislative advocacy by NHPCO and others led to the retroactive removal of the hospice wage index reduction until this next October. At that time, I presume it will be reinstated. Is this pork, is this stimulus, is this fair, was this the right place for this issue? We can debate that at the Annual Assembly if you want. Also the stimulus bill contained provisions for Comparative Efficacy Research (CER), which could be applied to many palliative care issues. Which works better methadone vs. oxycontin vs. fentanyl patch for pain? I am sure the research gurus in our field could come up with more ideas and get them funded to advance the science of our field.
And lastly what if the declining economy shifts the way health care is delivered? What happens when hospice and palliative care are not choices selected by patients, but become the non-autonomous 'consolation' prize of health care. 'Thanks for playing!' We may deliver great care to these patients, but if we are the providers of care for those who have no other choice, the risk of being resented and being rebuffed increases greatly, which could have broad impacts for our field.