After nearly 20 years in Congress, U.S. Rep Earl Blumenauer is getting ready to retire. Before he goes, though, he’s trying to land ambitious reforms to Medicare’s hospice benefit.
It’s not a new subject for Blumenauer. First elected to Portland’s 3rd District in Congress in 1996 and now in his seventh term, he floated legislation to have Medicare cover discussions with providers about end-of-life care and advance directives. Former Republican Vice Presidential candidate Sarah Palin framed the idea as it was reflected in the Affordable Care Act debate as “death panels.”
Now, amid increased coverage of Medicare hospice fraud and other abuses, Blumenauer has responded to increased pressure for reform with new draft legislation intended to ensure care and remove some of the incentive for fraud. In effect, it would unbundle the hospice benefit and shrink the portion of it awarded on a per-diem basis irrespective of care actually provided. Former President Jimmy Carter has spent more than a year in hospice care, which is designed for those thought to have six months or less to live.
The Lund Report spoke with Blumenauer about his draft bill, one local provider’s concerns about anti-fraud efforts, and the Congressman’s thoughts on health care reform in general. This interview has been edited for clarity and brevity.
The Lund Report: You say your draft legislation would be the first significant update to the hospice benefit in 42 years. Is that possible?
Earl Blumenauer: I’ve had a lot of history dealing with end of life care, palliative care, hospice stuff, and it's a struggle to get people to pay attention. I’m very excited about the draft we’ve written but in all seriousness, you know, we’re talking ‘82. And a lot has happened in this space. Well, Exhibit A is Jimmy Carter. You know, when we, when we started, this hospice was where people went to for the last few hours of life for maybe a day or two. Jimmy Carter’s going strong. And we understand the power of palliative care. And people do actually live remarkable, productive, pain-free existences, which is why we need to update this to reflect the realities of now.
TLR: What is the primary issue that you are trying to address with this?
Blumenauer: It’s part of a broader strategy I’ve had dealing with end of life and empowering patients. You know, I'm the death panel guy, right? Sarah Palin attacked provisions that I got in the Affordable Care Act that dealt with having the federal government put a value on that end-of-life conversation. It just was maddening to me that the federal government would pay thousands of dollars in health care for a terminally ill 95 year old cancer patient, but wouldn’t spend $100 (so) she and her family understood what her choices were, what was going to happen and how best to manage it. That just seems outrageous to me still. I mean, luckily, we got the federal government to put a value on that conversation. But we’re still struggling to have patients ask the doctors about it. And we have to fight to make sure that doctors have. And that’s one of the reasons that the majority of people die in hospitals, when nobody wants to die in a hospital. Nobody wants to be in an ICU hooked up to tubes and machines. We don’t put a value on working with patients to let them know what their choices are, right?e don’t try to make sure that we understand those choices and that their wishes are respected and enforced.
TLR: It seems like you’re trying to address fraud and abuse, but also lack of care.
Blumenauer: We want to strengthen the potential to have meaningful hospice care. Part of it is we’ve got to help people understand what’s available. And we’ve got to change it so that it keeps pace with the needs of patients and medical technologies. I mean, I mentioned Jimmy Carter, why shouldn’t we have concurrent care, palliative care, as well as curative — I mean, there’s no reason that just because the patient goes into hospice that we stop chemotherapy. Because people can live literally weeks, maybe months, with a hospice regimen, they ought to have the full range of treatments. The purpose is to give patients and their families what they want and what they need. And so we’ve got to catch up the payment regimen. We've got to change the rules and regulations. We’ve got to make sure that we get rid of the fraudsters. People get signed up for hospice and don’t even know they’re on it.
TLR: I don't know if you saw the article we published about Partners in Care in Central Oregon. They’re a nonprofit hospice provider and actually sued US Department of Health and Human Services earlier this year. They actually succeeded in eliminating quite a large portion of the debt that the feds were disallowing, but they ended up suing just because they felt that the system was stacked against them. The point that they’ve made and other people have made is that it’s so difficult to tell when someone is entering their end of life. Does your bill get into that at all?
Blumenauer: We don’t need to dance around on technicalities, you know, we're looking at revising the payment regimen. Part of what's a problem here is we pay this flat per diem, right? That is far more generous than many of these providers, what their actual costs are. We’re suggesting is payment reform that refines the per diem. But people are going to be responsible for actually delivering services in addition to just the per diem.
TLR: So you're sort of unbundling? You're increasing payments for specific, discrete services and treatments, while cutting the per diem?
Blumenauer: Essentially what this does is it rewards people who are doing it right. Makes it easier to get some of the specific services that frankly, with generalized per diem might be shortchanged, right? That’s expensive to do these special services for people, and they lump it all in the per diem. They take the money and they walk. But by unbundling it being specific about what we do, it’s easier to reward people who are doing the right thing, make it more likely that patients get the specific services they need. And the federal government ends up probably spending less, but it’s spent better.
TLR: Do you expect much opposition in Congress to this?
Blumenauer: I mean, we're proposing some pretty significant changes, people will have to modify their business models. We’re proposing cracking down on the cheaters and the shysters. And that always generates pushback, which I welcome.
TLR: What’s your advice to Oregonians when it comes to health care reform.
Blumenauer: We've got to be prepared to make some decisions that pinch, we’ve got to be able to accept the consequences. We need to be relentless in squeezing more value out of this gusher of money that we spend, that we’re not going to be able to spend indefinitely. I think we're all on the same side to try and reform, we’re in a better position (in Oregon). But this is what we have to do. Because we can’t keep going like this, spending exorbitant amounts of money for mediocre or even bad results, allowing outsized profits for people that don’t deserve it. That’s just not sustainable, and it’s not right, and we don’t have to do it.
