Subject: Pricing Health Care:  A Better Way to Die 
Date: Published: 5/19/93 (94 lines)
Source: Wall Street Journal. Copyright Dow Jones & Co. Inc.

    Pricing Health Care:
    A Better Way to Die
    ----
    By Carol Raphael

    News reports on the activities of Jack Kevorkian have drawn
 attention to the needs of the terminally ill and the wrenching
 decisions faced by them, their families and their physicians.  In my
 experience, most patients are less terrified of the act of dying
 than of dying an agonizing, impersonal and undignified death.
    Unfortunately, lost in the swirl of controversy is the
 recognition that there already exists an alternative approach to the
 excruciating pain and devastating alienation that too often is the
 unnecessary lot of the dying patient.
    That alternative is organized hospice care, a proven, effective
 and compassionate service to help the terminally ill patient through
 the dying process with dignity and in comfort.  Hospice care also
 helps the family through its loss and bereavement.  In contrast,
 hospitalization is costly, often inappropriate and frequently
 unwanted by the patient, while Dr. Kevorkian's desperate remedy for
 pain represents a medical and moral breakdown in our health care
 system.
    Hospice offers terminally ill individuals the option of spending
 their final weeks and months in the comfort and privacy of their own
 homes; in 90% of the cases we see at the Visiting Nurse Service of
 New York, the patient takes an active role in the decision to seek
 hospice care.  The hospice team -- nurse, physician, pastoral care
 counselor, social worker, home health aide and volunteer -- works
 collaboratively with the patient, the patient's family and the
 patient's physician to ensure maximum pain management, symptom
 control and comfort.
    While more than 75% of our hospice patients have advanced
 cancers, the services are appropriate for all dying patients,
 including those with Alzheimer's, cardiac disease, AIDS and severe
 degenerative neuro-muscular disorders, such as Lou Gehrig's Disease.
 Children, too, can be well served by hospice care.
    The process of dying is never an easy one, but the final days can
 be comforting for all involved; 98% of the patients in our hospice
 program die at home.  And the need for service does not end with
 death; bereavement counseling is available to family members for a
 year after the death of a loved one.
    Visiting Nurse Service of New York serves 30% of New York City's
 annual hospice population of approximately 2,000, yet we know that
 the number of people in hospice care is only a fraction of the
 number of terminally ill who could benefit from it.  Many families
 are still uninformed about hospice care or believe that hospice
 service is some form of institutional care.
    Part of the reason is that hospice care is new -- it started in
 Europe in the 1960s, where it is often institution-based, and was
 first introduced in the U. S. in the 1970s, where it is largely
 home-based.  Indeed, Medicare regulations require that certified
 hospice programs provide at least 80% of care in the patient's home.
 Initially a cost-saving regulation, it has proved to be a wise
 decision.
    Many physicians still do not fully understand the value of
 hospice care for their patients.  They may think they have to give up
 care of the patient.  They don't.  In fact, all orders for service in
 hospice care must be signed by the patient's physician, who can be
 an integral part of the hospice team.  In addition, trained hospice
 medical directors can work with those physicians who may have little
 or no training in aggressive pain management, feel unprepared to
 care for a patient seeking only palliative care, or are
 uncomfortable talking about death and dying.  We tell physicians that
 they should view a referral to hospice care as they would a referral
 to any other specialist.  And physicians who do refer patients to
 hospice care are likely to do it again.
    One of the surprising statistics about the American health care
 system is that our overwhelming reliance on caring for the dying in
 the hospital means, for example, that we spend 28% of all Medicare
 dollars for care in the last year of patients' lives and half of
 that for care in the last two months.  Here, too, hospice is a
 rational alternative.  The most recent study of hospice costs shows
 that when terminally ill patients are cared for at home, they spend
 six fewer days in the hospital and incur nearly 20% less in costs
 over a six-month period.  When a day of hospice care directly
 replaces a day in the hospital, the savings can be more than $500
 per patient per day.
    When a cure is no longer a reasonable expectation, the physician
 has an obligation to minister to his or her patient, to relieve
 pain, and to comfort and sustain the patient's family.  Modern
 hospice care can help the physician meet that basic obligation.
    ---
    Ms. Raphael is chief executive officer of Visiting Nurse Service
 of New York, the largest nonprofit provider of home health care in
 the U. S. 

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