Incarnating Heaven: Making the Hospice Philosophy Mean Business

The Journal of Sociology & Social Welfare Volume 23 Issue 3 September Article 3 September 1996 Incarnating Heaven: Making the Hospice Philosophy Mean Business Mark A. Mesler Massachusetts College of Pharmacy Pamela J. Miller Portland State University Follow this and additional works at: https://scholarworks.wmich.edu/jssw Part of the Clinical and Medical Social Work Commons, and the Social Work Commons Recommended Citation Mesler, Mark A. and Miller, Pamela J. (1996) "Incarnating Heaven: Making the Hospice Philosophy Mean Business," The Journal of Sociology & Social Welfare: Vol. 23 : Iss. 3 , Article 3. Available at: https://scholarworks.wmich.edu/jssw/vol23/iss3/3 This Article is brought to you for free and open access by the Social Work at ScholarWorks at WMU. For more information, please contact . Incarnating Heaven: Making the Hospice Philosophy Mean Business MARK A. MESLER Massachusetts College of Pharmacy & Allied Health Sciences Division of Arts & Sciences and PAMELA J. MILLER Portland State University Graduate School of Social Work Hospice providers in the U.S. are on the horns of a dilemma. Survival of individual programs may require accreditationfor third party reimbursement, but this stronger alignment with the business world of medicine mayjeopardize their unique philosophyof carefor dying persons. Hospice's current business/philosophydilemma was expressed succinctly by a study participantas attempting to incarnate heaven. Data gathered through an ongoing participant observation study reveals the effects of current third party reimbursementon hospice practice. Further,these effects have implicationsfor current U.S. health care reform efforts which are discussed in conclusion. By the 1960s and 1970s, dying in Western Society was increasingly characterized as depersonalized, and death itself as denied or invisible, and costly (e.g., Aries, 1974, 1981; Blauner, 1966; DeSpelder and Strickland, 1992; Gorer, 1965; Glaser and Strauss, 1965; Kubler-Ross, 1969, Mor, 1987). These characteristics were considered to be problematic consequences of the dominant Western medical model, with its emphasis on the curing of disease; death had been displaced from people's homes to institutional settings like hospitals and nursing homes. It was in this climate of discontent that contemporary hospice evolved. Journal of Sociology and Social Welfare, September, 1996, Volume XXIII, Number 3 32 Journal of Sociology & Social Welfare Hospice today is not so much a place as a philosophy which emphasizes palliative care, treatment of symptoms rather than disease, care rather than cure. Hospice concentrates on providing people with a terminal prognosis (generally six months or less) with the highest quality of life and personal control of the time which remains. Instead of dying in the depersonalized environment of institutions geared toward saving lives, hospice emphasizes dying amid familiar surroundings, friends and family (Corr and Corr, 1992; Mor, 1987). Moreover, hospice has often been discussed as a social movement, in part because it is attempting to change not only the way particular patients experience dying, but the nature of death and dying for society as a whole (Mesler, 1995a; Paradis, 1985; Stoddard, 1991). With the advent of Medicare and Medicaid, hospice attempted to bring its philosophy into the business world of U.S. health care. While some practitioners perceive this as affording hospice several benefits, some also believe it has posed serious dilemmas for remaining faithful to the philosophy, and for the movement's future goals. In this paper, we begin with a brief discussion of hospice's evolution into Medicare and Medicaid reimbursement. After a brief presentation of the research method and settings, we provide data exemplifying both the perceived advantagesand disadvantages of third party reimbursement. We then conclude with a discussion of the implications of these findings not only for hospice, but for future health care reforms and, thus, the processes of dying in the U.S. Background Hospice evolved rather quickly in the U.S. from a mostly volunteer, grassroots, community effort in the 1960s into a fullfledged relationship with the insurance industry by the 1980s (Keller and Bell, 1984; Osterweis and Champagne, 1979). In the 1970s and early 1980s there was a definite push among most hospice providers to acquire payment for services (Paradis, 1984); for example, in the early 1980s the Director of education and training at the National Hospice Organization commented, "Hospices which are able, consciously or not, to make a transition to seeing the program as a business are the most likely to succeed" (quoted IncarnatingHeaven 33 in Mor, 1987, p.17). Nonetheless, some of those involved in the hospice movement did not want to pursue third party reimbursement. Some of the small, all volunteer hospices organized and lobbied against Medicare funding for hospice care, claiming that the hospice philosophy would be undermined if allowed to enter the traditional health care system. In fact, a survey of 48 mid-western hospice programs conducted during this period found that those ".... that did not seek third-party reimbursement were truer, both in philosophy and practice, to the original hospice philosophy" (Mor, 1987; see also Cummings, 1985). Nonetheless, it seemed that the majority of providers were tired of asking for financial support through grants, donations, volunteers, and the United Way, and believed that hospice needed to enter the mainstream of health care in order to survive financially (Abel, 1986). Payment for hospice services began after passage of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 and, as a result of this legislation, services provided to terminally ill Medicare beneficiaries were recognized as a legitimate part of the health care benefit package offered to elderly Americans (Miller and Mike, 1995). The method of reimbursement for hospice care under Medicare was quite revolutionary at the time. Instead of the traditional fee for service, Medicare would pay a daily set rate for each day in a hospice program, referred to as a prospective method of payment (Katterhagen, 1986). The daily rate was set at a particular amount, regardless of the services offered on any day. In the years following TEFRA, Medicare's model for hospice services also became available to the poor through each state's Medical Assistance (Medicaid) program; while the prospective method of payment was generally adopted by such programs, the daily rates were sometimes set at lower levels. More recently hospice found a foothold in the private sector as well, for example through insurance coverage for those who work and receive health benefits. Many of these private insurance plans look very similar to the ones offered by Medicare and Medicaid. There is a daily rate which provides for a package of services, some of which the terminally ill perso (...truncated)