MEDICARE BENEFICIARIES comprise 80%–85% of all deaths in the United States annually.1 Among this group, approximately 92%, or 1.75 million deaths, occur in persons 65 years and older. Improving care at end-of-life should be a priority for the Medicare program and for providers of health care for the elderly. One strategy for improving care is to increase public awareness of the need to improve care of the dying and to garner public support for change. Recently, philanthropic foundations and media campaigns have sought to engage the public’s attention. Such campaigns attempt to educate the public on such issues as access to palliative care, quality of life, pain management, spirituality and support, and improvement of institutional practices in care of the dying. Another proactive strategy is for health professionals, particularly physicians, to become aware of the problems and to work toward improving existing care delivery systems. Health professionals and policy makers need to develop innovative new systems of care for terminally ill elderly. Public debate needs to be followed by changes within the Medicare regulations to allow for improvement and innovation. The latter requires legislative advocacy, particularly from organized medical societies. Finally, Medicare benefits for the frail and terminally ill elderly should be strengthened, enhanced, and better utilized. Examples of such benefits are the Medicare Hospice benefit, established by Congress in 1983, and Program of Allinclusive Care for the Elderly (PACE), legislated as part of the Balanced Budget Act of 1997. The number of Medicare beneficiaries served by hospice has increased significantly throughout the 1990s, but the program served just 19% of all Medicare decedents in 1998.1 Although the hospice benefit covers palliative care for the last 6 months of life, the length of service per patient remains short, with a national average of 48 days and median of 29 days in 1992.2 PACE, a relatively new Medicare benefit, specializes in care for frail Medicare beneficiaries 55 years and older.3,4
