Regulation for Palliative (Hospice) Care

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

The general adminstration published a circular regarding development of palliative care service in the community, general hospital and nursing institutions in order to turn palliative care into an integral part of the treatment proccesses. The services will be included in the basket of healtthcare services provided to HMOs members specified in the second appendix in accordance with the National Health Insurance Law and will be provided to a patient during several months before his/her death.

Recent developments

The general adminstration of the Ministry of Health published a circular for the implementation of palliative (hospice) care in the healthcare system. The general adminstration adopted the policy paper that was written by a committee appointed by the Ministry of Health in 2005. The policy paper adopted the definition of the WHO according to which palliative care is a therapeutic approach improving the quality of life of the patients and their famiy members, while coping with incurable diseases, by preventing and relieving the suffering via identification and careful evaluation of symptoms, mangement of pain and other problems, including physical, mental and spiritual problems. 

The new circular recomends integrating palliative care into the mandatory benefit package which is provided by the health plans. The objective of the circular is to assure universal access to palliative care to every person in need. It stipulates that the development of palliative (hospice) care service is essential as a basis for improving the quality of care and services in the community, general hospitals and nursing institutions. Development of palliative skills and services will enable physicians and medical staff to assist terminally ill patients coping with phyisical, psychological and social difficulties, as part of the comprehensive care provided to these patients, in order to enable them to live the last stages of their lives with dignity. The circular is focused on the palliative care provided to patients during several months before their death, and is applicable to both adults and children.

According to the circular the service is included in the basket of healtthcare services specified in the second appendix to the State Health Insurance Law. Accordingly, the HMOs and the institutions have to make all arrangements required for provision of these services, within four years of the issue of the circular, and to report to the Head of Medical Administration on their progress towards service implementation within one year of distribution of the circular. During the interim period, the HMOs and the institutions will at least use the avaliable services. During this period, it is important to enable training of various health care professionals in the field of palliiative care, including establishment of palliative care traning of physicians in the relevant fields.

In addition, according to the circular, the HMOs and every institution have to define the roles of a designated team for providing palliative care sercives. The team must include a physician, a nurse, a psychologist and a social worker. The cirdular also defined the target populations for palliative care services  - cancer patients with considerable physical and emotional distresses at any disease stage, including terminally ill cancer patients; patients with end stage heart failure; patients with end stage lung disease; patients with end stage liver failure; patients with end stage renal failure; patients with severe stroke; patients with advanced neurodegenerative disease and unconscious patients.  

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral
current    previous

Rather innovative: The MOH periodically issues circulars pertaining to services that are expected to be included in the benefit package of the National Health Insurance law. However, this is the first circular regarding palliative care. It is a rather innovative circulare, since palliative services are already provided in a minimal scope, and dependent on the initiative of local professionals who have a personal belief in the philosophy of hospice care. The new circular demands that the HMOs, hospitals and nursing homes supply the service so it will improve universal eligibility for this care.  

Moderate controversy: Although most stakeholders understand the importance of palliative  care and support the idea, there is concern regarding the source of funding. The HMOs are not willing to supply services without additional funds, and the Ministry of Finance is reluctant to increase the healthcare budget.  

Large systemic impact: The scope of palliative and hospice services is expected to significantly increase. Moreover, it will be included in the continuum of care for severe patients. It may also change the composition of hospital and nursing home beds (by reducing the number of acute and sub-acute beds). It is also expected to affect professional specialization and training.  

Low public visibility: Like many other circulars, its recommendations have not received media coverage, and have not yet been subject to public debate in various forums.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Initiators of idea/main actors

• Government: The MOH intitated and supported the recomendations to integrate palliative care into the mandatory benefit package which is provided by the health plans in order to assure universal access to palliative care to every person in need,

• Providers: HMOs, hospitals and institutions acknowledge the importance of these services, as they very often need to take care of terminally ill patients. However, they are concerned about whether these services will receive adequate budgets

• Patients, Consumers: Patients and palliative organizations are very supportive since there is evidence that patients are not adequately treated at the end of their life and that quality of end-of-life care is poor.

• Others

Stakeholder positions

The director general of the MOH initiated the circular in order to facilitate implementation of palliative and hospice care in the community, hospitals and nursing homes, and therefore of course strongly support it over time. The HMO directors acknowledge, today more than before, the importance of the service in order to supply good care to their enrollees. In addition, they aknowledge the potential contribution of the service to saving costs, rather than paying for high-tech and expensive care for dying patients. Nevertheless, they are still concerned about whether they will receive special budgets for supplying multidisciplinary hospice care.

Hospital directors are not united in their orientation regarding palliative care. While many support developing palliative care in order to improve quality of care and save costs, some believe that it is not their task and that general hospitals have more important tasks.

The positions of nursing institutions directors is unknown. Athough they should be the main target population to developing palliative services, they are only marginally aware of the circular. Moreover, palliative services hardly exist in nursing homes in Israel. The reasons for this include the everyday struggle with budget problems, lack of awareness of new services including palliative care, and having urgent day-to-day problems and tasks to solve.  

Naturally, palliative organizations are very supportive of the new circular, since it confirms the policy paper that was written by them in 2005 and since it supports their long and intesive activities to expand palliative care services. It supports the view that palliative care is a therapeutic approach improving the quality of life of the patients and their family members and that it is an integrated part of the mandatory benefit package which is provided by the health plans. Therefore it will assure universal access to palliative care to every person in need in the community, hospitals and nursing institutions. They are also satisfied with the recommendation to develop palliative skills which will help physicians and medical staff to assist terminally ill patients and their famiy members and enable them to live out their lives with dignity. The palliative organizations expressed their intention to assisst in the implementation of the new circular but since it was only published recently, they have not yet discussed their future activities.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
HMO directors	very supportive		strongly opposed
Hospital directors	very supportive		strongly opposed
Nursing home institutions	very supportive		strongly opposed
Patients, Consumers
Patients	very supportive		strongly opposed
Palliative organizations	very supportive		strongly opposed
Others
Geriatritians	very supportive		strongly opposed
Family Physicians	very supportive		strongly opposed
Community nurses	very supportive		strongly opposed
current    previous

Actors and influence

Government
Ministry of Health	very strong		none
Providers
HMO directors	very strong		none
Hospital directors	very strong		none
Nursing home institutions	very strong		none
Patients, Consumers
Patients	very strong		none
Palliative organizations	very strong		none
Others
Geriatritians	very strong		none
Family Physicians	very strong		none
Community nurses	very strong		none
current    previous

Positions and Influences at a glance

Adoption and implementation

According to the circular, the HMOs, hospitals and nursing institusions have to make all arrangements required for the provision of palliative services within four years of issue of the circular, and to report to the Head of the Medical Administration on their progress towards service implementation within one year of distribution of the circular. During the interim period, the HMOs and the institutions will at least use the avaliable services. The palliative organization expressed the intention to assisst in the implementation of the new circular but since it was only published recently, they have not yet discussed their future activities.

Monitoring and evaluation

According to the circular, its implementation will be controlled within the setting of the Medical Administration audits. No formal evaluation of the process or outcomes of this new policy is yet planned or published.

Expected outcome

There is an expectation that in a few years, comprehensive palliative care services will be offered to all terminally ill patients and their families while today only about 10% to 15% of those in need of this care actually receive it. Access to palliative care will be improved dramatically all over the country, and will be supplied by the HMOs accoring to the national health insurance benefits package.

These changes will improve quality of care and increase equity. Moreover, there is an expectation that physicians will refer patients to palliative care earlier than today, thus, patients may receive palliative care for longer periods.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high
current    previous

The published circular will have a positive effect on the quality of end-of-life care since the health funds, the hospitals and the nursing institutions will be obligated to develop palliative services, which are minimal today. These will improve the accessibility of palliative services for the patients and their family members who are coping with incurable diseases ,since the services will be an integrated  part of the mandatory benefit package which is provided by the health plans.

References

Sources of Information

• Bentur N, Resnizky S, Shnoor Y (2005). Palliative and Hospice Services in Israel. Research Report: RR-459-05 (In Hebrew, executive summary in English)
• Bentur N. (2008) The Attitudes of Physicians Toward the New "Dying Patient Act" Enacted in Israel. American Journal of Hospice and Palliative Medicine 25:361-365
• Cherny, N.I. (2003) The problem of suffering. In D. Doyle, G. Hanks, N. Cherny, K. Calman (eds.) Oxford Textbook of Palliative Medicine. Oxford: Oxford University Press, 7-14
• Shnoor Y, Szlaifer M., Aoberman A, and Bentur N (2007). The Cost of Home Hospice Care for Terminal Patients in Israel. American Journal of Hospice & Palliative Medicine. Am J Hosp Palliat Care. 24: 284-290 

Reform formerly reported in

End of life care policy Process Stages: Implementation

Author/s and/or contributors to this survey

Netta Bentur

Dr. Netta Bentur, senior researcher at the Aging Division of the Myers-JDC-Brookdale Institute and associate professor at the Emek Yzrael College.

Suggested citation for this online article

Netta Bentur. "Regulation for Palliative (Hospice) Care". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/is/a14/2