When it was initiated in 1982, the hospice benefit was expected to save Medicare money by eliminating hospital-based treatments that people didn't want.  Hospice was untested so Congress took steps to cap the benefit in order to control spending.

The cap had two parts.  First, a lifetime cap that limited each beneficiary to a maximum of 210 days of hospice care.  Second, a cap on the amount each hospice provider could bill in a single year.  The goal was to limit hospice spending to 40 percent of hospital costs. 

Initially, 95 percent of those in hospice care were terminal cancer patients who had grown weary of treatment options.  They stayed only days or weeks.  Few ever hit the cap.

As hospice care became a preferred option for patients the limitations of the Medicare benefit became apparent.  One barrier quickly addressed by Congress was providing hospice services to non-cancer patients.  Many were at the end of severe illness but capable of out living the cap on the benefit.

Legislation was passed in 1998 that eliminated the cap on an individual's right to receive hospice care, as long as a physician continued to certify the patient as terminal.  Medicare developed objective standards to define hospice eligibility for each of the major non-cancer diagnoses.  Eligible patients are now entitled to remain enrolled in hospice services until they die, regardless of the length of their stay.

Today nearly 50 percent of Medicare beneficiaries who die received some hospice care, and the share of hospice patients with non-cancer diagnoses has increased from less than 10 percent of all hospice patients to more than 50 percent.  When expanding the hospice benefit, Congress neglected to remove or modify the cap on the hospice provider.  As medically-eligible patients stay longer in hospice care, many providers reach their cap and must refund Medicare money that has already been spent on patient care.

Hospices are hitting their cap at an alarming rate.  In 1997 virtually no hospice hit the cap.  In 2004 hospices in 15 states did, repaying Medicare $100 million.  Estimates show that hundreds of hospices in at least half of the states will be asked to repay Medicare this year.

In my state of Oklahoma alone a third of hospices may hit the cap this year.  Rural communities like those I represent don't have extensive health care alternatives.  When hospices are forced out of business many Medicare beneficiaries will be faced with the choice of dying in pain or in a hospital bed where they do not wish to be.

It shouldn't be like this.  Congress needs to find a way to fund the care for eligible hospice patients as Congress intended.  In the meantime we need to reevaluate what remains of the government-imposed cap on hospice care.

Congressman Dan Boren (D-Muskogee) represents Oklahoma's Second Congressional District in the U.S. House of Representatives. To learn more visit http://www.house.gov/boren/

July 2007