The physician gatekeeper: access to the Medicare hospice benefit.

The origins of U.S. hospicephilosophyin the early1970’sgrewfrom a holistic, self-help,anti-physician,antitechnologybias; a reputationthatstill lingers in medical circles. This nonmedical,volunteerbeginningof many hospicesplacedthehospicemovement outsidethemainstreamhealthcaresystem, atfirst by the choiceof hospices, andlater by physiciansand hospitals withholding referrals.Medical costcontainmentefforts embeddedin Federalhealthpolicylegislationled to theenactmentof theMedicarehospice benefitand the expansionof hospice services.For thosewho struggledfor somanyyearsto aiddyingpersonsand advancehospicecare, the Medicare hospicebenefitsymbolizesthesuccess of their efforts. Thoughaspectsof the benefitmay be imperfectlyconceivedand implemented,it is abeginningandis infinitely preferableto no beginning.Access issuesare important becausethe benefit mustbe used by the greatest possiblenumberofeligiblepersonsfor hospicestosurvivefinancially, andit is importantforpatientsto beableto access their Medicare hospiceentitlement at a fmancially and personally stressfultime.Whenthebenefitis fully utilized,thecreativemedicalskills and humane,holisticcaringthataretheessenceof hospicewill hopefully impact theoverallcareofseriouslyandchronically ill patients,no matterwhat roles hospitalsandphysiciansmayplay.This hasalreadybegun. In choosing to focus on the physicianas a gatekeeper controlling accesstotheMedicarehospicebenefit, I recognizethat thereareotherimportantaccessissuesaswell: • regulatory disincentivesfor hospicesto becomeMedicare certified; • patientandfamily reluctanceto acknowledgea terminalprognosisdue to personalandcultural variables; • financial incentivesfor hospitals andhomehealthagencies to keep eligible patients in MedicarePartA aslongaspossible;and • lackofknowledgeabouthowto accesshospiceservicesin low income and minority communities. Accessandphysician lossof control