Webcast Questions
The following questions were submitted via the Internet during NCCS’ Town Hall in Cleveland, Ohio, on April 25, 2003. Because of time constraints, program panelists were not able to respond to all of the questions submitted during the Town Hall. We asked two of our panelists from Ireland Cancer Center at University Hospitals of Cleveland/Case Western Reserve University—Meri Armour MSN, RN and Nathan Levitan MD—to respond to the remaining questions. We have posted their responses below.
1. What’s the difference between hospice care and palliative care?
Meri Armour MSN, RN: Hospice care, by definition of the Centers for Medicare and Medicaid Services (CMS), is the last six months of life while palliative care implies supportive care over time.
Nathan Levitan MD: Palliative care focuses on the patient’s comfort and quality of life. Hospice is a particular program of care with a specific array of services paid for by Medicare and most other insurers. Hospice provides palliative care. However, there is much palliative care that is given by providers who are not part of hospice.
2. Why are some patients, families or physicians reluctant to utilize hospice services?
Armour: Fear, denial, confusion, anguish.
Levitan: Some patients or families believe that enrolling in hospice is synonymous with the final few weeks or months of life. In fact, it is most advantageous to establish a relationship with hospice providers much earlier. A failure to understand this makes some people reluctant to seek hospice services.
3. As an oncology social worker, I’m concerned about the lack of social workers’ presence in hospitals with oncology units. This could have a tremendous effect on the patient’s and family’s ability to cope and deprives them of the advocacy they often need. Is NCI encouraging the presence of social workers within oncology programs?
Armour: There is no requirement specifically for oncology social workers.
Levitan: I cannot speak for the NCI. However, at the Ireland Cancer Center, we extensively incorporate a broad array of psychosocial and nutritional services for all of our patients.
Susan Scherr (NCCS): Several years ago NCI Comprehensive Cancer Centers were required, but not funded, to provide supportive and psychosocial care services, but that is no longer the case. NCCS has advocated for this type supportive care since its founding in 1986, but many hospitals do not have the financial resources to provide it. In some cases where social workers are funded, they often spend the majority of their time handling paperwork and trying to get insurance authorization.
4. How are hospice care and palliative care paid for under private insurance, Medicare and Medicaid? Regular billing?
Armour: Medicare and Medicaid both pay for hospice, as do many commercial payors; palliative care is not uniquely paid for as a service.
Levitan: Briefly, it is a managed care benefit with a daily payment by Medicare to hospice. In return, the hospice must provide nursing and home health aid services and pay for medications pertaining to the diagnosis that is the cause of the hospice admission. Separate payment rates are established for care at home, admission to an inpatient facility for respite care and admission for symptom management.
5. How are programs like Project Safe Conduct likely to be funded after grants and such are over?
Armour: Through philanthropy and other research grants mostly, certain services within the Safe Conduct Team are reimburseable such as clinical psychologist.
Levitan: This is an excellent question. We are looking for funding at this time. Unless third party reimbursement policies change, this can only be funded through grants and charitable contributions.
6. What were or are the barriers to instituting the care model of Project Safe Conduct?
Armour: This is a topic for long discussion . . . some thoughts are money, goal direction, physician resistance, knowledge deficits, etc.
7. Project Safe Conduct is an incredible model for enabling patients and families to pursue aggressive treatment while receiving palliative care and support. The one area that I find lacking is integrative medicine services component under one roof or group . . . such as acupuncture, meditation, music therapy, massage, nutrition service that include herbals, etc. I have seen this carried out in a wonderful way at some cancer centers. Can I assume that this is part of the long-term plan for patients on an outpatient and in-patient basis?
Armour: Complementary care is very important to patients and families within cancer care and all cancer centers are trying to figure out how to sponsor such activities/education.
8. In light of the criticalness of joining concurrent cancer care and palliative care, are or have there been any steps in including these concepts, practices and theory into the requirements/curriculum of all oncologists? This could assure patients the quality of care and life we all aspire to.
Armour: For the very first time, questions about palliative care are now part of the oncology boards.
Levitan: The American Society of Clinical Oncology emphasizes to its members the important role of the oncologist in managing the symptoms of cancer in addition to fighting the cancer itself. Educational programs are provided in this regard at the national meetings, and related articles appear regularly in the Journal of Clinical Oncology. Physician training programs are increasingly incorporating these topics into their curricula as well.
9. I’m concerned as an oncology social worker, that patients seeking hospice, desiring TPN, care for drainage tubes (i.e. in lungs) or palliative chemo or XRT treatments are having difficulty being accepted into hospice programs due to the way Medicare and Medicaid reimbursements are made. Is this being considered politically? It seems that hospices only want patients who are willing to die as quickly as possible. Please understand I greatly respect and appreciate the care hospices provide but I’m concerned about this trend.
Armour: That has not been our experience with Hospice of the Western Reserve and as long as the hospice entity focuses on the mission--is this patient terminal--then services that seem appropriate become crystal clear as to their need/benefit/etc.
Levitan: I totally agree that hospice programs should be allowed to accept patients that require palliative treatments of the type that you have described. This will require a change in federal medical regulations pertaining to hospice funding.
Click here to view the Town Hall webcast using Windows Media Player.
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