Opposing The Palliative Care and Hospice Education and Training Act (2023); S. 2243 (118th Congress)

*Bill S. 2243 is not currently moving but the sponsors of the bill are still working to get it debated or inserted within another piece of legislation.

Link to The Palliative Care and Hospice Education and Training Act (Bill S. 2243)

EPC-USA Position Statement

The Euthanasia Prevention Coalition USA supports positive measures to improve peoples’ quality of life and well being instead of offering them assisted suicide and euthanasia. We are aging and disability advocates, lawyers, doctors, nurses and politicians.

Palliative care defined by hospice pushes patients with chronic serious illness down a path toward death long before they become terminal.(1) Palliative care defined by hospice and insurers is focused on cost-cutting where “quality and comfort take a backseat to profits” with a disparate impact on low-income patients and people of color.(2) We believe people should be empowered to live well with chronic serious illness without placing them at risk of hospice abuse, serious harm and premature death.(3)

Talking Points

1. The Bill wrongly links palliative care with hospice instead of primary and specialty care for non-terminal patients, thereby pushing them down a path toward premature death.

• The Bill repeatedly links palliative care with hospice even in the few places it mentions integration with primary and specialty care.
• Proponents say palliative care should start upon diagnosis of chronic serious illness.(4) Life expectancy at diagnosis averages 5-10 more years;(5) many people will live longer. Palliative care should be part of their primary and specialty care, not linked to hospice in the Bill.
• Palliative care linked to hospice leads to the deaths of people who are not otherwise dying; typically by indifferently assessing people as terminal and providing them “comfort care” where they are heavily sedated, overdosed on pain killers and denied food and water so the prognosis becomes self-fulfilling.(6)

2. The Bill is equated to euthanasia and assisted suicide by supporters. 

• Compassion and Choices says the Bill will enable people to access a peaceful death.(7) They urge their followers to equate support for the Bill to support for Medical Aid in Dying, their euphemism for euthanasia and assisted suicide, in contacts with Congress.(8)
• The Bill’s Section 5 limits on funding of euthanasia and assisted suicide are unenforceable. The first on education and training in grant funded classes is not enforceable because HHS does not have the data; the second applies to the furnishing of care under the Act, but the Act funds education, research and public information, not the furnishing of care.

3. The workforce shortage to be met by the Bill has disappeared. 

• The seminal 2018 study that says the shortage of palliative physicians in 2040 will range from 2,500 to 5,000 and can be eliminated by growing fellowships to 500-600 per year.(9)
• Available fellowships reached 518 in 2020-21 without PCHETA(10) which is likely why it is now being described as addressing future (not current) needs.(11)
• From another perspective, the “shortage” disappears when we count the more than 39,000 family/general practice physicians(12) who currently provide palliative care.

4. Palliative care’s focus is on cost-cutting where “quality and comfort take a backseat to profits” with a disparate impact on low-income patients and people of color.(13)

• The Center to Advance Palliative Care (CAP-C) says “Palliative care is for all individuals with serious illness who face heightened risks of crisis hospitalization and preventable spending −often over years.”(14)
• An NBC investigation says a national hospital chain nudges patients into palliative care as a gateway to hospice to reduce regular mortality, readmission and length of stay metrics.(15)
• Hospices are already using palliative care as a “loss leader” to enroll more patients into hospice earlier.(16) The HHS OIG reported people were inadequately informed their care had switched to hospice and sometimes were placed in hospice without their knowledge.(17)
• Private equity investors are increasingly buying hospice and palliative care companies.(18)
• Private equity ownership increased deaths and costs to the government for nursing home residents,(19) which is likely in other settings as well.
• Insurers offering Medicare Advantage plans, like Humana and Anthem,(20) are running palliative care programs, with clinicians working for insurers.

5. The Bill would spend $100 million over five years and likely forgo hundreds of millions in fraud recoveries that could be better spent elsewhere. 

• The HHS OIG says hospices are enrolling patients who are not terminally ill without their knowledge or under false pretenses, providing poor quality care, and wrongly billing Medicare hundreds of millions of dollars.(21)
• The HHS OIG says hospices are defrauding Medicare of hundreds of millions of dollars by enrolling people who are not terminal and then billing at the highest rates.(22) Most hospice settlements listed on the Fraud in Healthcare site are for enrolling ineligible people.(23)
• The only legal Medicare reference to palliative care is care provided to hospice patients. 42 CFR 418.3. The Bill could erase federal fraud recoveries for enrolling non-terminal people in hospice by extending eligibility for palliative care (as a type of hospice care) to those with a “serious or life-threatening illness”, to be defined after enactment by federal bureaucrats and palliative care insiders (Bill Section 904(c)(3)).

6. The Bill substitutes a stamp of approval by the Agency for Healthcare Research and Quality (AHRQ) for patient safety concerns about dangerous hospice and palliative care.

• Bill Section 4 permits the Agency for Healthcare Research and Quality (AHRQ) to disseminate only positive information about palliative care, thereby silencing AHRQ’s concern about palliative care safety issues(24) and evidence-based recommendations.
• Clinical practices in hospice-style palliative medicine regularly shorten lives.(25) This is so prevalent it was described by the Washington Post in a 2014 series26 and identified as a serious problem by Duke University professor Farr Curlin, M.D.in 2015.(27)
  

End Notes:

1. Blog post at https://www.multiplechronicconditions.org/blog/u-s-senate-defeats-the-deadly-palliative-care-bill-for-thethird-time/ by Dr. Kim Kuebler, a palliative care nurse and thought leader. https://www.linkedin.com/in/drkimkuebler/
2. Letter linked to at https://www.finance.senate.gov/chairmans-news/wyden-brown-warren-probe-private-equityownership-of-kindred-at-home
3. https://oig.hhs.gov/oei/reports/oei-02-16-00570.asp linking to the complete report; https://oig.hhs.gov/oei/reports/oei-02-17-00020.asp linking to the complete report; Peter Whoriskey, As More Hospices Enroll Patients Who Aren’t Dying, Questions about Lethal Doses Arise, Washington Post, August 21, 2014 https://www.washingtonpost.com/news/storyline/wp/2014/08/21/as-more-hospices-enroll-patients-who-arent-dyingquestions-about-lethal-doses-arise/
4. https://getpalliativecare.org/palliative-care-can-help-right-diagnosis/
5. Murray SA et al., Illness Trajectories and Palliative Care, BMJ. 2005 April 30; 330(7498): 1007–1011.
6. Farr A. Curlin, M.D., Hospice and Palliative Medicine’s Attempt at an Art of Dying, chapter 4 in Dying in the Twenty-First Century, edited by Lydia Dugdale, MD, MIT Press 2015 at pages 47-8.
7. https://www.compassionandchoices.org/docs/default-source/default-document-library/pcheta-endorsement-letter---final---6.7.22.pdf?sfvrsn=b731f7fb_1
8. https://join.compassionandchoices.org/a/thank-senator-baldwin-today?sourceid=1075543&emci=863203ed-89ecec11-b47a-281878b83d8a&emdi=11ef0ed9-99ed-ec11-b47a-281878b83d8a&ceid=1588667
9. Lupu D, et al, The Growing Demand for Hospice and Palliative Medicine Physicians: Will the Supply Keep Up? at https://www.jpsmjournal.com/article/S0885-3924(18)30031-9/fulltext is pointed to be AAHPM at http://aahpm.org/career/workforce-study and by CAPC https://www.capc.org/documents/download/1093/
10. https://aahpm.org/uploads/Program_Data_102820.pdf
11. https://www.capc.org/documents/download/1093/
12. 118,198 physicians practice family/general practice medicine. https://www.aamc.org/data-reports/data/2020-physician-specialty-data-report-executive-summary One-third or over 39,000 say they provide palliative care. https://patientengagementhit.com/news/33-of-primary-care-providers-also-deliver-palliative-care
13. Letter linked to at https://www.finance.senate.gov/chairmans-news/wyden-brown-warren-probe-private-equityownership-of-kindred-at-home
14. CAPC, The Case for Community Based Palliative Care 2021 at p 6, at https://www.capc.org/documents/867/
15. https://www.nbcnews.com/health/health-care/doctors-say-hca-hospitals-push-patients-hospice-care-rcna81599
16. https://hospicenews.com/2019/05/14/study-71-of-u-s-adults-have-never-heard-of-palliative-care/ A loss leader is a service sold below cost to attract more customers who will then buy more profitable services. www.businessdictionary.com/definition/loss-leader.html
17. https://oig.hhs.gov/oei/reports/oei-02-16-00570.asp linking to the complete report.
18. See note 2.
19. https://www.nber.org/papers/w28474
20. See note 2 for Humana. Anthem owns Aspire, a palliative care company. https://d3d8hkm9o9zt51.cloudfront.net/ourcompany
21. https://oig.hhs.gov/oei/reports/oei-02-16-00570.asp linking to the complete report.
22. See note Error! Bookmark not defined..
23. https://fraudinhealthcare.com/results/?entity%5B%5D=301
24. https://search.ahrq.gov/search?q=palliative+comfort+harm
25. Cohen L, et al., Accusations of Murder and Euthanasia in End of Life Care, J Pall Med 2005.8.1096 at 1102.
26. Peter Whoriskey, As More Hospices Enroll Patients Who Aren’t Dying, Questions about Lethal Doses Arise, Washington Post, August 21, 2014 https://www.washingtonpost.com/news/storyline/wp/2014/08/21/as-more-hospicesenroll-patients-who-arent-dying-questions-about-lethal-doses-arise/
27. Farr A. Curlin, M.D., Hospice and Palliative Medicine’s Attempt at an Art of Dying, chapter 4 in Dying in the Twenty-First Century, edited by Lydia Dugdale, MD, MIT Press 2015 at pages 47-8.