It didn’t take a hard sell to convince Joe Brannigan that he needed hospice care.

The longtime former legislator and executive director of Shalom House, a nonprofit mental health agency, had been a vocal advocate for end-of-life care, and he helped to raise money to build the Gosnell Memorial Hospice House in Scarborough.

When his body could no longer fight the incurable leukemia that eventually claimed his life in January at age 83, he chose to be cared for at his home in Portland by nurses, aides and social workers from Hospice of Southern Maine. They helped Brannigan with bathing, managing medications and other end-of-life issues.

“They really know what they’re doing,” said Claire Brannigan, his wife of 47 years. “I was impressed with the level of care they provided. It was a very good experience for us.”

Despite the widely acknowledged benefits of hospice care, however, only 46 percent of the 2.1 million Medicare patients who died in 2013 used their hospice benefits, according to the U.S. Department of Health and Human Services.

Some people are unaware of hospice care, or they think they don’t qualify, or they avoid it because they see it as giving up rather than taking charge. Sometimes, however, physicians fail to inform their patients about end-of-life options because they’re unfamiliar with hospice care, or they’re focused on curative care, or they want to avoid a difficult conversation.

Joe and Claire Brannigan with their son, Luke, at Two Lights State Park in Cape Elizabeth in the late 1970s.  Photo courtesy of Claire Brannigan

Joe and Claire Brannigan with their son, Luke, at Two Lights State Park in Cape Elizabeth in the late 1970s. Photo courtesy of Claire Brannigan

To help Medicare beneficiaries better understand and navigate their end-of-life options, starting in January, physicians will be able to bill Medicare for advance care planning discussions they have with patients. Under a new rule from the Centers for Medicare & Medicaid Services, doctors will be reimbursed about $80 for half-hour conversations with patients who have a terminal diagnosis on topics such as preparing a living will, designating a health care proxy, choosing a hospice provider and other end-of-life decisions.

“It’s about ensuring that people get the care they want,” said Dr. Mark Wrona, a palliative and hospice care expert at New England Cancer Specialists in Scarborough. “It sends a message that it’s important to start having these conversations. And if physicians aren’t comfortable having these conversations, they need to learn how or put their patients in touch with people who can.”

EXPERT CARE, LESS EXPENSIVE

Wrona and other health care providers acknowledge there’s a financial benefit for Medicare in the face of a rapidly growing senior population.

Medicare spending on hospice care increased from $2.9 billion in 2000 to $15.1 billion in 2014, but it’s still three to 14 times cheaper than acute care provided in a hospital. Hospice care costs $162 per day at home or $722 per day at the hospice house, while the typical inpatient hospital stay in Maine cost $2,238 per day in 2013, according to CMS.

“It’s a bit cynical to think lack of reimbursement is the only reason some physicians aren’t having these conversations,” said Dr. Thomas Keating, medical director at Hospice of Southern Maine. “It will definitely encourage them. It will be interesting to see how much. Hopefully it will lead to better care.”

Opponents of the new rule worry that unscrupulous physicians might “railroad” patients into receiving less care, Keating said.

An emotional Joe Brannigan is honored in 2002 by having his name placed on the Shalom House in Portland, where he started working in 1975. 2002 Press Herald file photo/John Patriquin

An emotional Joe Brannigan is honored in 2002 by having his name placed on the Shalom House in Portland, where he started working in 1975.
2002 Press Herald file photo/John Patriquin

“But really, it’s an opportunity to provide information and document a patient’s wishes,” Keating said. “It’s supposed to be an impartial conversation about options.”

Patients often want to hear their physician’s opinion about their prognosis, Keating said, and it’s their responsibility to share that information, even if it’s a difficult conversation. Unfortunately, he said, most doctors have had little training in end-of-life care, in part because the focus of medical school is largely on curing illness.

Given the pending Medicare billing change, Hospice of Southern Maine is considering ways that it can provide educational opportunities for physicians who want to learn more about end-of-life care and how to talk about it with patients.

“The conversations are certainly not easy, and there will need to be additional education for some physicians,” said Daryl Cady, CEO of Hospice of Southern Maine. “But end-of-life discussions need to be part of the life cycle. We need to give patients and families much more control at this very important time of their lives.”

SPENDING TIME TOGETHER

The Brannigans embraced that control. The assistance of hospice workers freed Claire, a retired nurse, to be a present, supportive partner through the last three months of Joe’s life. She used the free time to take a shower, do household chores or go to the pharmacy. A licensed social worker before he retired, Joe Brannigan chatted with the hospice workers and pressed them to share what they knew about what lay ahead.

Claire and Joe Brannigan at their wedding in 1972. Photo courtesy of Claire Brannigan

Claire and Joe Brannigan at their wedding in 1972. Photo courtesy of Claire Brannigan

“He wanted to know what to expect and they were able to talk with him about it,” his wife, 70, recalled. “They had real expertise, not only about his (terminal) diagnosis, but also about the services hospice provides. And they never seemed to be in a rush.”

Keen to give his wife a break, Joe Brannigan spent one week at Gosnell Memorial Hospice House in so-called respite care, which is covered by Medicare. During that week, Claire Brannigan had lunch with friends and went to a movie, but mostly she spent time at the hospice house with her husband. They read newspapers each day and chatted. After serving more than 27 years in the Maine Legislature as a representative and a senator, Joe Brannigan still loved to talk politics with his wife.

“We were able to just be together and enjoy each other,” Claire Brannigan said. “It’s so much better to go through the process with awareness and appreciation than to avoid talking about it.”