The physician's responsibility under the new medicare reimbursement for hospice care

New legislation to provide Medicare reimbursement for hospice care has created problems for physicians who are involved in the treatment of the terminally ill. Under current proposals, hospice services will be reimbursed by a certain amount per patient-day, according to four categories of level of care, and for a maximum of 210 days. At 210 days, reimbursement will cease, but the hospice program will not be allowed to discharge the patient. The Medicare hospice benefit requires physicians to certify that their patients have six months or less to live before the patients are considered candidates for hospice care; under the new reimbursement policy, both the rights of patients to receive services and the financial stability of hospice programs will thus come to depend heavily on the accuracy of these prognostications by physicians. We wish to address three questions: What is the scientific accuracy of such prognostications? What can be learned from analogous circumstances in which physicians have been asked to make judgments for which there is no scientifically valid basis? and What is the best response from physicians to the current hospice problem?