Persons who formerly would have received a Medicaid benefit for hospice care under Alabama law will no longer have it, effective Nov. 1, if a proposed Alabama Medicaid Agency change goes through. That means some terminally ill patients may not receive hospice care after Nov. 1.

Although hospice agencies &045; for-profit and non-profit &045; are required to care for indigent patients, some services could well be cut because of reduced funding and the inability of agencies to raise additional funds to close the gap through private sources.

Ironically, November is National Hospice Month.

According to the National Hospice and Palliative Care Organization, 45 states currently provide Medicaid hospice benefits and two of the five remaining are on the brink of adding the benefit. Which means Alabama is taking a major step backward if the cut goes through.

The proposal to cut Medicaid reimbursements for hospice care became known to the Alabama Hospice Organization (AHO) in late September, when high officials of the Alabama Medicaid office confirmed it, according to an AHO letter to providers.

Under the revised state budget, Medicaid was ordered to make a cut in the Medicaid budget for the next fiscal year and the proposal is that Medicaid funding of hospice care for terminal patients, an optional benefit under federal law,

be eliminated. Unless the proposal is reversed by the agency before Nov. 1, it will go into effect &045; and that has hospice workers and families with Medicaid-eligible family members plainly worried.

Local reactions

Workers at the two hospices with facilities in Selma were contacted for their reaction to the proposed cut.

These are Wiregrass Hospice, a non-profit entity and part of a chain of

16 such facilities in Alabama, Florida and Georgia, established 14 years ago and headquartered in Dothan. The other is Cahaba Hospice Inc., a for-profit stand-alone entity, which was founded by CEO Barbara Ware, a registered nurse in 1996. It is located at 410 Church St.

At both agencies, staff members expressed extreme alarm at the proposed cuts, fearing that some families of patients will be unwilling or unable to seek assistance at the end of life of their loved ones and concern about the addition of the burden at such a time of how to pay for it.

The depth of love and caring of staff members interviewed at both agencies was self-evident. Hospices are not known for high-paid staff and those who gravitate toward end-of-life care have a deeply rooted faith and concern for others.

Of the proposed cut, social worker Ann Curtis of Cahaba Hospice

said. &uot;It is outright discrimination against the poor,&uot; referring to the fact that only indigent patients are eligible for the Medicaid hospice benefit.

Ware added: &uot;I’m really aggravated about it, but we will continue to provide the care to those who need it.&uot;

Beth Williamson, community education worker on staff of Wiregrass Hospice, echoed Ware’s commitment to continue services: &uot;We will continue to care (for Medicaid patients who need hospice care) as a matter of corporate policy.&uot; However, both Ware and Williamson observed that the cut will stress agencies, because the dollars that would have supported this care will have to be raised from other sources. Hospice care has come into vogue since the late 1960s and early 1970s and is a widely utilized end-of-life program that operates 24/7. It is an approach dedicated to the principles that there can be dignity in death, and easing the passage from life to death for terminally ill patients. As Ware writes in her interpretative brochure: &uot;The mission of Cahaba Hospice is to ensure quality of life and a comfortable, peaceful death for all patients receiving our care, and to provide support for their loved ones.&uot;

Through hospice, the terminally ill and their families are enabled, with the help of comprehensive support from a multidisciplinary team of health-care professionals, to enable most patients to stay at home and, in some cases, to continue usual activities to the extent possible. In addition, bereavement support for survivors continues for up to 13 months. Patients must be referred to hospice by a medical doctor.

The National Hospice and Palliative Care Organization estimates that 95 percent of hospice patients’ care is provided in the home; that hospices now care for more than half of all Americans who die from cancer and a growing percentage of those dying from other major diseases; and that hospices are the leading caregivers for terminally ill patients with HIV/AIDS.

There are three primary sources of funding: Medicare (since 1983), Medicaid (at a state’s option, since 1985) and private insurance. According to the National Hospice and Palliative Care Organization (NHPCO),

more than 80 percent of hospice patients are Medicare beneficiaries. Additional funding must be raised from gifts and donations to bridge the gap between reimbursements and actual costs, which are paid to licensed hospice programs on a per diem base. Per diem covers medications, equipment and home care &045; everything needed to manage pain and symptoms, at the same time dealing with the emotional, social and spiritual needs of the patient and family, according to NHPCO.

Hospice organizations also rely extensively on volunteers. In fact, the volunteer coordinator at Cahaba Hospice is herself a volunteer, according to Ware.

Estimates regarding the proposed amount of the cut statewide range from $14-$18 million, according to Williamson. Eighty percent of the total &045; whatever it turns out to be &045; goes for reimbursement for nursing home room and board, Williamson said. The remaining 20 percent goes for hospice care, exclusive of nursing home room and board.

That is, only $2.96-3.6 million would be actually saved by the proposed cut, she calculated. Points being made by providers and their representatives to reverse the state Medicaid office proposal include the fact that

The Medicaid Hospice Benefit comprises only 0.61 percent of the FY 2002 state Medicaid budget. The average cost to the state per hospice patient is about $6,500 and it is estimated that hospice saved the state

Medicaid more than $4

million in 2002 over what would have been paid, by reducing days spent in the hospital and eliminating unnecessary interventions at the end of life.

Because Medicaid pays a per diem rate for all services provided, it is estimated that Alabama Medicaid saved the state some $86,832 in outlays for prescriptions in 2002.

An Alabama Medicaid Agency report on FY 2002 noted that &uot;The service (hospice) is not only compassionate but also cost effective.&uot; According to the report Medicaid supported 2,572 hospice patients in FY 2002 at a cost of about $19 million, which was more than offset by a reduction in hospital costs for Medicaid. Opponents of the cut also note that

The number of people using Medicaid Hospice is limited because such persons must be under 65, impoverished and be diagnosed with a terminal condition, with less than six months left to live.

Alabama Medicaid could realize additional savings, because of applicable reimbursement formulas, if more use of hospice were made by nursing homes.

In the words of a recent news release from NHPCO, &uot;Alabama’s budget woes are considerable, but government officials and the public should know that proposed cuts of in-home hospice care will most likely increase costs instead of decreasing them as Medicaid officials hope. Hospice is clearly the most compassionate means of caring for terminally ill patients, but it has also proven the most cost efficient.&uot;

For further information, contact Cahaba Hospice Inc., 410 Church St., Selma, AL 36701 (334-418-0566; 1-888-418-0570; www.cahabahospice.com); Wiregrass Hospice, 200 Central Park Plc., Selma, AL 36701 (334-875-2120; www.wiregrasshospice.org); Alabama Hospice Organization, P.O. Box 1835, Calera, AL 35040-1835 (800-355-1973; info@alhospice.org).