Death and Profits

When Hugh Westbrook pioneered hospice care, his organization saw to the needs of the dying. Fifteen years later nothing has changed -- except the politics and the profit margins.

In 1978 Westbrook and Colliflower, a nurse who had raised eight children before embarking on a career in teaching, formed South Florida's first formal hospice program A Hospice of Miami. "We had no money," Westbrook remembers. "There was no reimbursement from Medicare, and all of the home-health people tried immediately to put us out of business. They went to the state and complained that we were taking care of patients without a license and doing home care without a license. And they were right. We were. We didn't know any

better, we were all volunteers."
The next year, 1979, Westbrook trooped up to Tallahassee to fashion a special license for hospices. Luckily a friend of his had just been elected to the legislature: Carrie Meek. The former state representative (now a member of Congress) had taught at Miami Dade Community College at the same time as Westbrook and Colliflower. "We used to do leadership seminars together for students," Westbrook notes. "So I went to Carrie and said we needed a licensing law that defines hospice separate from everyone else. I sat down with a yellow legal pad and outlined the law, what it was we wanted. We were trying to do something different for dying patients and give them an alternative."

Among the provisions of the proposed law: all hospices had to be nonprofit and they had to provide care regardless of whether a person had the ability to pay. "We did those things to stop the Medicare-mill type operations and to keep the for-profit home-health industry from jumping into hospice and taking it over," he says without mentioning the irony of his current position as a for-profit giant. "You have to realize that hospices are generally small community organizations. They couldn't stand some big corporation coming in with competing interests. Putting those requirements in, we've kept a lot of people out."

Meek used Westbrook's notes to draft a bill, but by then it was too late to have any new measures introduced for that 1979 session. Meek and Westbrook appealed to State Senator Jack Gordon for help, knowing the Dade Democrat was a powerful politician. "Jack talked the Speaker of the House into waiving the rules to allow Carrie to introduce the bill," Westbrook explains, "and Jack agreed to sponsor the bill in the Senate." With his bill now introduced, Westbrook had to get it passed. "For the first time in my life I went up and started lobbying."

Almost immediately he picked up another important ally, the wife of then-Governor Bob Graham. "I ran into her at a hearing," Westbrook recalls. "Bob had been a state senator from my area. My church was in North Miami Beach. I talked to her about hospice, and she thought it was great and she got behind it." Eventually so did everyone else. "The idea of taking care of dying people the way we do is pretty difficult to be against," he says. The hospice bill passed both the House and the Senate -- unanimously - on the last day of the legislative session.

The Florida law that Gordon and Meek sponsored was the first in the nation legally recognizing hospices and establishing procedures for them to become licensed. But it was really nothing more than a piece of paper. "We had sort of outsmarted ourselves," Westbrook muses. "What we found out was that the license and a quarter would get you a part of a cup of coffee."

That same year, 1979, the Carter administration decided to experiment with the hospice concept as a way to bring down the cost of health care. Twenty-six hospice programs around the nation would be selected as test cases and would be allowed to seek reimbursement for their services through Medicare. Westbrook cites one study that claims 40 percent of the money spent on health care during a person's life is expended during the final twelve months. Doctors, Westbrook says, simply got into the habit of placing terminally ill patients in a hospital bed A where the costs are exorbitant A even when there wasn't any hope for recovery. By caring for a patient in his home, through a hospice program, the patient could spend his final days or weeks in a more comfortable and less expensive environment.

"We applied and we were selected," Westbrook says, still somewhat amazed. "We were surprised because at the time we didn't know anyone in Washington. This gave us the financial base to take this idea that Esther and I had, and instead of taking care of one patient at a time, which is what we were doing, we actually were able to get up to five patients at a time."

Their program in South Florida began to expand. They branched into Broward and called their new operation Hospice Inc., which of course was nonprofit in keeping with the Florida law. They went from serving one patient at a time to five, then to dozens.

Westbrook was confident the Medicare experiment would prove that hospices were cost effective. But there was no guarantee Congress would accept the results and permanently expand Medicare coverage to hospice programs. Before the test results were announced, he began organizing nationally to lobby Congress. "We found that there was a hospice group, or somebody trying to put together a hospice, in every single congressional district in the country," Westbrook says. "We pulled those people together and we started to lobby."

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