Hospice care is holistic care for the dying.  Medicare coverage of hospice care is available for beneficiaries who have been certified as terminally ill, for services that are “reasonable and necessary for the palliation or management of the terminal illness as well as related conditions.”  Prior to receiving Medicare coverage for hospice care, beneficiaries must sign a hospice election form which indicates that they have a “full understanding of the palliative rather than the curative nature of hospice care as it relates to the individual’s terminal illness.”

Medical dictionaries define palliative care as care that affords relief, but not cure.  Curative care, on the other hand, is defined as care that tends to overcome disease, and promote recovery.  So a Medicare beneficiary who is terminally ill with cancer, and who elects the hospice benefit, would expect that her pain medications and therapies (including palliative chemotherapy) would be covered by Medicare, but were she to receive chemotherapy for the purpose of curing her cancer, the curative chemotherapy would not be covered.  This distinction between palliative and curative care seems easy enough.  However in reality, the palliative/curative divide is not so easily discerned.

For instance, a person with end-stage renal disease, who has been certified as terminally ill, would probably be told that she could not elect the Medicare hospice benefit until after she discontinued her dialysis.  Dialysis, of course, is the process of removing waste products and excess water from the body.  Without dialysis, a person with end-stage renal disease would most likely die within a two week period.   In other words, this beneficiary would be told that in order to receive Medicare covered hospice care, she would have to sign her own death sentence, a death sentence with a time line of less than fourteen days.   Talk about a Hobson’s choice.

But is this dilemma really necessary?  Dialysis for an individual with end-stage renal disease is clearly not curative.  Then, therefore, it must be palliative.  And since it is palliative, it should be covered by Medicare under the hospice benefit.

However, there remains yet another problem.  Hospice programs that provide care to terminally ill Medicare beneficiaries are paid a per diem.  From that per diem, hospice programs must pay for all the care that is rendered to the Medicare beneficiary.  The hospice per diem is simply not enough to pay for dialysis.  So despite the fact that they are otherwise qualified to receive Medicare coverage for hospice care, beneficiaries with end-stage renal disease, and other beneficiaries with terminal illnesses who are receiving expensive life-sustaining, but not curative care, are barred from hospice care because of the Medicare payment system.  This is a travesty.  It is a travesty that the Centers for Medicare & Medicaid Services should remedy.