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From the September 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

Hospice care

I was saddened to read that internists at an Annual Session presentation on end-of-life care "angrily denounced Medicare rules they fear will subject them to fraud charges if a patient lives longer than the allocated 180 days." ("Helping patients find their way to a 'good death'," June ACP-ASIM Observer, p. 2.)

To facilitate prognostic decision-making, the National Hospice Organization has developed guidelines for predicting six-month longevity for eight noncancer diagnoses. These policies, which have been adopted by the Medicare regional home health intermediaries, as well as a more recent policy on assessing hospice eligibility based on "clinical decline," establish criteria for admitting patients to hospice.

While these written criteria were designed to help physicians, failure to meet them does not automatically exclude a patient from hospice. Physicians are expected to use and document whatever other criteria they feel is justified to predict that a patient will live for six months or less based on a normal course of disease.

It is understood and expected that some patients will live longer than six months while in hospice, either due to the unpredictable nature of their terminal disease or because of the care they receive while in hospice. The challenge for physicians is to move their terminal patients into hospice early enough to receive optimal benefits during the last six months of their lives. The challenge for the hospice movement and policy-makers is to develop and validate criteria to improve clinicians' ability to predict their patient's life expectancy at the end of life.

Physicians admitting patients under Medicare's hospice benefit are not being targeted by fraud investigators, and the fear of being subject to fraud charges for the occasional patient who lives more than 180 days is misplaced. The hospice benefit is generally working well, but clinicians need to work to make it serve their patients even more effectively. This cannot happen if clinicians refer patients appropriate for hospice late, or refer patients who are not appropriate for hospice in the first place. It can only occur when physicians refer the right patient to the right setting at the right time.

John W. Olds, FACP
Des Moines, Iowa

Editor's note: Dr. Olds is medical director for a Medicare regional home health intermediary.

Universal access

The news that ACP-ASIM is working with six other major medical associations to make universal coverage a key issue in the year 2000 elections was both welcome and disappointing. ("Physician groups unite for universal coverage," July/August ACP-ASIM Observer, p. 1.) Although the Physicians' Work Group on Universal Coverage stopped short of declaring access to health care a right, as it is deemed in every other industrial country, it at least aims to make access a national goal, as we watch the 43 million uninsured grow by 100,000 a month.

What the work group did not mention is that even for the shrinking number of Americans with adequate and affordable health insurance, our current system is sick and getting worse. Managed care has been a failure. It undermines trust in the doctor-patient relationship by paying physicians more for giving less care and penalizing them for giving "too much." It restricts patients' choice of doctor and hospital, leaves treatment decisions to nonprofessionals and ignores the working uninsured.

The fatal flaw in this sick system is that corporate insurers ultimately report to shareholders, not patients. It is clear to a growing number of physicians that we must, at last, excise the profit-taking middleman that stands between doctor and patient. The solution, accepted in one form or another around the industrial world, is national health insurance. Since the work group only announced a goal but not the best way to get there, there is, so far, less to their statement than meets the eye.

James Bernstein, FACP
Rockville Centre, N.Y.

I pray that the time has finally come for universal access. In my state, Florida, 24% of the population is uninsured, and many more are underinsured.

The problem is growing rapidly, coincident with medical costs. While the public here in Indian River County picks up some of these costs, this is by no means true in much of the rest of the United States.

Across the country, it is hospitals that often pick up most of these costs. That is why some of our best academic medical facilities, along with community hospitals of every stripe, are going broke. We must continue to hammer this message home in Washington.

Burton J. Lee III, FACP
Vero Beach, Fla.

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