MediCaring demo may be introduced in Congress

Aging Alliance shatters end-of-life care myths

MediCaring, a proposed new model of comprehensive end-of-life care loosely modeled on hospice but intended for a much broader population of patients with life-threatening illnesses, may soon get a hearing in the court of public policy.

Developed by Director Joanne Lynn, MD, and her staff at the Center to Improve Care of the Dying at George Washington University, Washington, DC, MediCaring could find life in legislation now being drafted by Sen. John D. Rockefeller IV (D-WV).

According to an unpublished position paper by Lynn and center Senior Scientist Anne M. Wilkinson, PhD, MediCaring "would focus on comprehensive, supportive, reliable community-based services, shaped by preferences, with priorities of symptom management and family counseling and support. It would be funded by a daily or monthly capitation payment to special multidisciplinary teams of providers . . . without increasing average [Medicare] costs, mainly by diminishing the use of acute care interventions that may no longer serve the patient."

In addition, the project would define thresholds of severity of illness for eligible patients. Government agencies would be directed to develop quality outcomes measures for end-of-life care and the Secretary of Health and Human Services would report annually to Congress on the state of such care. Lynn roughly estimates that a program of this magnitude could cost $5 to $10 million.

"Hospice services, though quite popular, are limited by provisions of the enabling statute and how it has been implemented to serving only a fraction of those who die, and then mostly for a month or less before death," the draft proposal states. Hospices now primarily serve patients with cancer and AIDS. "Medicare beneficiaries with other diseases — the vast majority of older adults — generally do not have access to hospice care, mostly because their illnesses do not have ‘predictable’ phases of decline at the end of life," the proposal states.

"Some will construe MediCaring as an expansion of hospice, or a blend of home care and hospice," Lynn tells Hospice Management Advisor. Some of the demonstration programs funded under this initiative "could be hospices, but more likely they will be innovative, hospice-like approaches. It’s unlikely we’d end up with a program that mimics hospice. But it’s not clear whether it would be the same service providers, or whether hospice is so well-adapted to its particular niche that we’d be better off to leave it alone and learn from it. Or should we fold hospice into a broader program?"

More data are needed to answer the questions, Lynn says. "There’s some reason to think that hospice now serves its niche well, but maybe one group of service providers could serve all patients at the end of life" using community emergency response teams, she adds. "I think there’s also room for a straightforward evaluation of hospice itself."

While acknowledging that some hospices might feel threatened by this proposal and other developments in the rapidly emerging field of end-of-life care, Lynn observes, "Hospice has not attended well to building its own case. It can’t be the case that all hospices are wonderful — there are too many of them."

‘Seven deadly myths’ at the end of life

Meanwhile, the Washington, DC-based Alliance for Aging Research in May issued a report arguing that much of the current decision-making in health care is "based more on fiction than fact," according to Alliance executive director Daniel Perry.

The study, called "Seven Deadly Myths: Uncovering the Facts About the High Cost of the Last Year of Life," is based on a review of Medicare data and the medical literature by the Alliance, an independent not for profit citizen advocacy organization.

Among the report’s conclusions:

• The majority of the elderly already die outside the hospital, while the very old are more likely to die in nursing homes.

• The growing age of America’s population does not appear to be the primary driver behind rising health care costs.

• Limiting acute medical care at the end of life would save only a small fraction of the nation’s total health care bill.

• Only a fraction of people over age 65 receive aggressive high-technology care at the end of life, and the older they are, the less likely they will receive such care when dying. However, many older people who receive aggressive care survive and do well for an extended period — thus challenging the belief that providing such care for the elderly is money wasted, the report concludes.

The report was sponsored by the Project on Death in America and the Retirement Research Foundation.

[Editor’s note: For more information or copies, contact the Alliance for Aging Research, 2021 K St., NW, Suite 305, Washington, DC 20006-1003. Telephone: (202) 293-2856.]