Stephen Kiernan knows about dying. He has witnessed the worst and best ways of leaving this life. “My father’s end-of-life care involved every imaginable medical extravagance, which in retrospect I believe was torture. It also cost a fortune,” he said. “Five years later, my mother died pain-free at home in her bed, with her prayer book in her hand and family at the bedside. And it cost one-tenth as much.” Years later Kiernan, who lives in Charlotte, would write “Last Rights: Rescuing the End of Life from the Medical System,” and hear more than 10,000 stories like his own from readers of his book. “When I started researching end-of-life care, I learned that the dilemmas that my brothers and sisters and I faced with our parents were not unique – they were commonplace. About 6,000 Vermonters die every year. About 1,400 of them have my mother’s experience, thanks to hospice and palliative care, and having an advance directive in place. The rest of those Vermonters suffer avoidable physical pain, preventable emotional anguish and unnecessary intervention and expense,” he said. “This is not like mapping the human genome or inventing the artificial heart,” Kiernan added. “We know how to take good care of people in the last chapter of their lives. We need a greater commitment to doing that.” More than 80 percent of Vermonters say they want to die at home, yet most die in a hospital or nursing home – except for one group. Three out of four people enrolled in hospice care die in their own homes.1 But Vermont ranks near the bottom nationwide in hospice use: Medicare spending on hospice care per Vermonter is well below the national average. Read about U.S. Hospice Utilization by State. Supporters of a bill that passed unanimously in the House hope it will increase the number of Vermonters who take advantage of hospice. The intent of H.201, “An Act Relating to Hospice and Palliative Care,” was to remove obstacles that discourage patients from choosing the service by:directing the state – and urging private insurers – to take the steps needed to provide an “enhanced hospice access” benefit removing the barriers of access to Choices for Care for hospice patients taking measures to ensure that patients do not receive unwanted treatment, and do receive desired treatment, in a medical emergency and providing that practitioners of medicine and surgery complete 10 hours of continuing medical education to renew their licenses. What’s the difference between hospice and palliative care? Mel Huff explains. A study conducted by Aetna, the insurance company, inspired the section of H.201 that provides for expanded hospice benefits. In 2005, Aetna launched a pilot project that offered a group of participants “enhanced hospice access”: Patients with a diagnosis of a terminal illness and a life expectancy of 12 months were permitted to elect hospice care. They were also allowed to continue curative treatment while they received hospice services. Currently, patients must acknowledge that they have only six months or less left to live and agree to forego curative therapies in order to receive Medicare hospice benefits. Most private insurers follow Medicare’s lead. Aetna reported that the enhanced hospice benefit and nurse case management resulted in an increased use of hospice, a decrease in acute care and lower use of services provided in hospitals. Medicare data show that a quarter of all health care costs are incurred by intense medical treatment in the last six months of life; hospice care is much less expensive. The net result of the Aetna pilot was a 22 percent decrease in costs. In September 2009, Aetna began offering enhanced hospice benefits to most employer groups. Read the Palliative Care and Pain Management Task Force Annual Report, 2011. Cindy Bruzzese, the executive director of the Vermont Ethics Network Rep. Bill Frank, who introduced H.201, pointed to three elements that contributed to the success of the pilot project. First, Aetna’s nurse case manager followed the patients to make sure they were getting appropriate care. Second, receiving a prognosis of a year of additional life seemed less daunting to patients than a six months’ prognosis. And third, after entering the hospice program, patients who felt they needed curative therapies they had previously received could still receive them. Chemotherapy, for example, is sometimes used for palliative purposes, although Medicare considers it curative. Under the present hospice guidelines, cancer patients who enter hospice can’t receive chemotherapy. “One reason people don’t take advantage of hospice is that they don’t want to admit they’re near the end of life, and they don’t want to give up curative care – they think they will have pain,” Frank said. “But Aetna found that if you allow people to be able to go back on curative care, even if for a short time, it not only helps the patient, because they know they’re not giving it up completely, but it also helps them have a better quality of life. When we reviewed this report, this was very promising for both patients and for saving money. Something that’s better and costs less money – talk about a ‘win-win’ situation!” H.201 requires the state to apply for Medicare and Medicaid waivers to allow Vermont to provide enhanced hospice access, and it recommends that insurance companies provide similar benefits. “That’s a substantial extension of hospice,” Frank observed. Cindy Bruzzese, the executive director of the Vermont Ethics Network, echoed his remarks. “We have some evidence now that shows that we can improve quality of life for patients, improve patient and family satisfaction, reduce the repeat admissions and acute admissions to the hospital and also reduce costs.