Author: Ruth M. Thomson, DO MBA HMDC FACOI FAAHPM
As one of AAHPM’s delegates, I had the privilege of representing the field of Hospice and Palliative Medicine at the American Medical Association (AMA) House of Delegates (HOD) 2023 Annual Meeting held in Chicago in mid-June. At the meeting, I presented the lead testimony for our delegation on the two AAHPM-authored resolutions related to hospice policy.
View the full resolutions as adopted (note that only the “Resolved” clauses become enshrined as AMA policy):
The resolution which called for AMA advocacy aimed at improving hospice program integrity easily passed as written. The other resolution, which urged AMA action in support of modernizing the Medicare Hospice Benefit, recommended incorporating a number of components:
- Hospice eligibility should not be based solely on a specified prognosis
- Patients must have a choice in their hospice provider
- Services should be provided by a full interdisciplinary team
- Patients and their caregivers should have adequate support in-home or facility settings
- Patients should have concurrent access to disease-directed treatments
- Payments to hospices should be sufficient to support the needed quality and scope of services
- The hospice benefit should be consistently applied across Medicare contractors
- Quality and value-based metrics should align with what matters most to patients and caregivers
Surprisingly, we received strong dissent from some of our colleagues in oncology on the latter resolution, which was steeped in misperceptions about concurrent care and about the nature of hospice medicine generally. A few of the arguments presented against the resolution were that: 1.) hospices cannot afford to pay for all disease-directed treatments with the current reimbursement structure, 2.) would hospice physicians be expected and prepared to manage all disease-directed treatments (e.g., chemo- or immunotherapy), and 3.) concerns that patients may be less apt to stop nonbeneficial treatments if they can have treatment and also receive hospice services.
On the flip side, we also received significant support from some of our specialist colleagues, particularly the American Academy of Pediatrics. Delegates from AAP cited the already successful pediatric concurrent care models while others pointed to the effectiveness of concurrent care in the Veterans Administration. All highlighted the needs of patients and their families.
During discussions at the AMA Pain and Palliative Medicine Section Council – which is chaired by AAHPM delegate Chad D. Kollas, MD FACP FCLM FAAHPM HMDC – and during testimony in the HOD, I made the case that the benefit was enacted 40 years ago and does not meet the needs of our patient population today. Drawing on examples from my 20+ years in hospice medicine, I shared how the current structure creates barriers to access for patients and families and leads to inequities for patients in marginalized populations.
We know this issue also leads to moral distress for Hospice Medical Directors. Since the current benefit does not incorporate concurrent care, Hospice Medical Directors must grapple with which medications and treatments the hospice can afford, rather than what aligns with patient and family wishes. Patients and their families too often must choose all or none – give up all disease-directed treatments to have hospice services or stay on those treatments and forgo the needed care and support from hospice they deserve.
The experience cemented for me that it is critical for AAHPM to be “at the table” to advocate for issues important to our field. We not only must address misinformation in the general medical community but seize the opportunity to lead with policy ideas. We offer an important voice for patients who cannot always speak for themselves.
On behalf of all of the Academy’s delegates – myself, Chad, Ana L. Leech, MD MS FAAHPM (Alternate Delegate) and Kyle P. Edmonds, MD FAAHPM (Young Physicians Section Delegate), thanks to all the Academy members who joined the AMA in 2023 to “Count Us In” and ensure AAHPM’s continued representation at the HOD, so we can be a part of this important work.