chronic obstructive pulmonary disease (COPD), renal diseases and AIDS, minority groups significantly underutilize palliative and hospice services. In 1990, 93 percent of patients utilizing the Medicare hospice nenefit were Caucasian (Christakis et al., 1996). The National Hospice and Palliative Care Organization (NHPCO) has concluded that less than 10 percent of all hospice patients are African American. In addition, less than 10 percent of patients utilizing hospice services in the national for-profit chains are minorities. Medicare data culled over an eight-year period (1992–1996) supports this conclusion: minorities make up only 14 percent of the U.S. population that is taking advantage of the Medicare hospice benefit. Consequently, costs for African Americans who are not taking advantage of the benefit in the last year of life are substantially greater. According to the Medicare Payment Advisory Commission (MedPAC), the average cost for African Americans in the last year of life was approximately $32,000 compared to $25,000 for Caucasians (Medicare Payment Advisory Commission, 2000). The MedPAC data did not show higher costs in the last year of life for other minority groups. In addition, MedPAC statistics also revealed a higher percentage of non-hospice inpatient deaths for minorities compared with Caucasians. These last two points need more careful review to understand the full implications for financing health care for African Americans and other minorities facing terminal disease.

Barriers to Utilization of Palliative and Hospice Care

If care is to be improved for African-American and other underserved groups when there is a diagnosis of a life-threatening disease or chronic debilitating illness that may end in death, knowledge of the reasons for the current underutilization of palliative care and end-of-life services must be clearly understood. Unequal access to care in general or a lack of access to palliative and end-of-life care services may be one reason for underutilization. Few physicians know about palliative care alternatives, so they are unable to advise their patients adequately and sufficiently. Another reason for underutilization of palliative care services in the African-American community may stem from a lack of knowledge of federal, state, and local benefits associated with end-of-life health care needs. A failure to address specific cultural and spiritual needs of patients that may not be articulated well or at all by the patient and family could also contribute to underutilization of these services.

Historical Perspective

Historical and societal factors also may act as barriers to the use of palliative and hospice care today in the African-American community



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