Hospice at Home: Historical Perspectives and Their Implications for End-of-Life Care Today

Outcomes 1. Describe critical influences in the development of the Medicare hospice benefit.2. Apply a historical approach to reflect on reasons for socioeconomic disparities in end-of-life care today. Key Message Forty years ago, political and economic forces shaped the Medicare hospice benefit in a way that prioritized home death, shifting responsibilities and financial costs onto patients and caregivers. These political and economic influences arguably have perpetuated disparities in end-of-life care until today. Abstract In 2017, home surpassed the hospital as the most common location of death in the United States. However, individual choice does not always drive the decision to be at home at the end of life. This presentation will take a historical approach, drawing on primary and secondary sources, to identify key political and economic factors that have influenced end-of-life care and that perpetuate inequitable access to a comfortable death. By understanding the history of our current system, we can understand how to improve it.To illustrate the underrecognized political and economic factors that led to the American push to die at home, we will trace the development of the modern hospice movement and subsequent creation of the Medicare hospice benefit. Compared to hospices today, early hospices were heterogenous and informed by available resources and the unique needs of their patient populations. The political drive to shift health care costs away from the government and private insurance played an important role in the timing and structure of the Medicare hospice benefit. When approved by Congress in 1982, the benefit standardized hospice care and included a particular emphasis on home care, despite a lack of evidence to do so. As a result, the original benefit included a 20% cap on inpatient days and centered family members as the primary, uncompensated, caregivers.A look at changes in end-of-life care after the Medicare benefit went into effect illustrates its lasting impact on dying. The number of hospices rapidly expanded, thereby increasing access to compassionate end-of-life care. Early hospice leaders, however, criticized the benefit for failing to meet the needs of individuals with limited family support. Through open discussion, we will ask participants to interrogate the links between the hospice benefit's structure and socioeconomic disparities that persist in end-of-life care today. Keywords Models of Palliative Care Delivery; Advocacy / Policy/ Regulations