Dialysis is a life-sustaining treatment for people with end-stage renal disease (ESRD). Treatments usually last four hours and are done three times per week. People who have lost 85% or more of their kidney function and who quit dialysis usually have about one week to live. Then why would Medicare require people to give up dialysis to receive hospice, and, if that is the case, is there a way around this rule?
How Does Hospice Benefit People with Kidney Failure?
Hospice offers the same benefits for people with kidney failure as for any person in the last months of life. The service sends nurses, therapists, aides, volunteers and other workers to the homes of patients. Hospice workers specialize in palliative care for people with advanced, terminal diseases. Therefore, hospice improves symptom control, emotional support, care coordination, patient/family satisfaction, and quality of life during a very important time.1,2 Receiving medical care at home reduces the need to be in a hospital, nursing home, or emergency department. Among dialysis patients specifically, hospice cuts Medicare spending by more than two-thirds, lowers hospitalizations 53%, and lowers intensive care procedures 90%.3 Less travel to and from hospitals increases comfort, rest, and peace of mind for families. It also gives people the option to die at home, which is what most patients prefer. Hospice is a very important service for dying patients and for their families. It should be denied to no one.
Hospice is for End-of-Life Care
Medicare limits hospice to people who have six months or less to live should the disease follow a normal course. As part of this rule, Medicare will not pay for hospice and curative treatments at the same time. The thinking is if a patient is pursuing a cure, the doctor shouldn’t say he or she has six months to live. Normally this rule does not interfere with treatment. Doctors refer to hospice when there is nothing left to do medically. Patients who are not at the end-of-life or who are pursuing cures can choose palliative care, but that is not hospice.
Medicare Misclassifies Dialysis as Curative
Unfortunately, Medicare has misclassified dialysis as a curative treatment.3 Medicare’s misclassification means patients must choose between life-sustaining dialysis treatments or the best end-of-life care program available. Dialysis has never cured end-stage renal disease. Dialysis is no more a cure for ESRD than insulin is a cure for diabetes or oxygen is a cure for COPD. Medicare does not require patients with COPD to give up supplemental oxygen for hospice. Nor does Medicare require diabetic patients to give up insulin. Only patients with kidney disease are denied hospice this way.
How Patients Can Get Hospice and Dialysis at the Same Time
Medicare provides a loophole. In 2014, Medicare ruled that hospice will be considered palliative, not curative, if the primary hospice diagnosis is not ESRD. This refers to the paperwork your hospice creates and the doctor signs. Hospice will create a list of each patient’s diagnoses. The diagnosis at the top of the list is the primary hospice diagnosis. An obvious example of a case where this would work would be if a person on dialysis developed cancer. The hospice agency could list cancer as the primary hospice diagnosis, and Medicare would pay for both hospice and dialysis.
Is this loophole available to everyone? Probably not. A study published recently in the Journal of the American Medical Association shows that people on dialysis use hospice much less than the general population (27% vs 48%). People with ESRD also receive hospice less than people with other organ failure diseases.
- Schockett ER, Teno JM, Miller SC, Stuart B. Late referral to hospice and bereaved family member perception of quality of end-of-life care. J Pain Symptom Manage. 2005; 30(5):400–407.
- Rickerson E, Harrold J, Kapo J, Carroll JT, Casarett D. Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better? J Am Geriatr Soc. 2005; 53(5):819–823.
- Wachterman MW, Hailpern SM, Keating NL, Tamura MK, O’Hare AM. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Internal Medicine. 2018 June; 178 (6): 792-799.