There were several unintended consequences that developed out of the hospice benefit made permanent under COBRA. Some of the problems had to do with the lack of clear guidelines regarding areas such as the six month time limit, the prospective method of payment, and the emphasis on care being provided at home. In addition, other issues such as the conflict between the medical model and hospice and the lack of informed choice for patients continue to hinder the utilization of hospice.
The Medicare hospice benefit was intended for individuals who, according to their physician, had less than six months left to live. The writers of this clause overlooked the ambiguity of what this clause presents. Former Senator Bob Dole, who spearheaded inclusion of hospice care when he was chairman of the Senate Finance Committee, said the six-month rule was barely discussed when it was written, and was “not meant to be a barrier or a limit; it was meant to be a guideline” (Lipman, 2000, Sep 19). However, the Health Care Finance Administration, that regulates Medicare, was enforcing the six-month limit as a way to curtail Medicare fraud and lower costs of care. This made doctors more cautious with their prognosis and as a result patients were admitted with as little as two weeks before dying (Miller & Mike, 1995). This short stay denied family and the patient the full range of supportive services that hospice promotes regarding coping and adjusting to the critical end stage of life. The philosophy of hospice was being short-changed and misunderstood.
The Medicare reimbursement of hospice makes it difficult for hospices to ensure adequate care for patients. Medicare reimburses hospices at a fixed daily rate for each patient, which ignores individual needs. “A certified hospice always runs a risk of spending more than what Medicare would reimburse because of this process” (Miller & Mike, 1999, p.539).
A third outcome that has presented unintentional problems is the emphasis on providing hospice care in the home. TEFRA outlined that eighty percent of the care given by a hospice had to be provided in the patient’s home as opposed to an inpatient facility (Gage et.al, 2000). This implies that there is a caregiver available 24 hours a day in the home before a person is accepted into a hospice program. The problem that arises is that many patients do not have access to this kind of support, and therefore are unable to utilize hospice care.
Outside of the actual legislation there are overriding social implications to this Act. The first implication is the conflict between the philosophy of hospice and the medical model of treatment. Physicians are trained to treat and cure patient, which is inconsistent with the hospice philosophy. “Physicians may deny access to hospice services because of their own inability to admit that the patient is not going to recover” (Sontag, 1992, p.19). This can pose an ethical dilemma for doctors who take an oath to preserve life when the prognosis is uncertain.
As a result, doctors might not even propose hospice as a choice to their patients. “Eighty percent of Americans do not consider hospice as an option for end of life care” (National Hospice Foundation, 2000, p.1). Based on the 1996 National Home and Hospice Care Survey, 84% of hospice patients were White (Haupt, 1998). Some possible explanations for the under utilization of hospice by ethnic minorities could be that they are not aware that it’s a choice, cultural variations of death and the perception of dying, access to Medicare/Medicaid, and as stated earlier lack of caregiver support (Gage et. al, 2000; Miller & Mike, 1995).