Despite its demonstrated potential to both improve quality of care and lower costs, the Medicare hospice benefit has been seen as producing savings only for patients enrolled 53–105 days before death. Using data from the Health and Retirement Study, 2002–08, and individual Medicare claims, and overcoming limitations of previous work, we found $2,561 in savings to Medicare for each patient enrolled in hospice 53–105 days before death, compared to a matched, nonhospice control. Even higher savings were seen, however, with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1–7, 8–14, and 15–30 days prior to death, respectively. Within all periods examined, hospice patients also had significantly lower rates of hospital service use and in-hospital death than matched controls. Instead of attempting to limit Medicare hospice participation, the Centers for Medicare and Medicaid Services should focus on ensuring the timely enrollment of qualified patients who desire the benefit.

Background End-of-life medical expenditures exceed costs during other periods, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs. Objectives To 1) identify patient-level determinants of Medicare expenditures at end-of-life and 2) determine these factors’ contributions to expenditure variation while accounting for regional characteristics. We hypothesized that race/ethnicity, social support and functional status are independently associated with treatment intensity, controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation. Design Using Health and Retirement Study (HRS), Medicare claims and Dartmouth Atlas of Health Care data, we modeled relationships between expenditures and patient and regional characteristics. Participants and Setting HRS decedents 65.5 years or older (n=2394), 2000–2006. Measurement Medicare expenditures in last 6 months of life were estimated in a series of 2-level multivariable regression models including 1) patient, 2) regional, and 3) patient and regional characteristics. Results Decline in function (rate ratio 1.64, 95%CI 1.46–1.83), Hispanic ethnicity (1.50, 1.22–1.85), African American race (1.43, 1.25–1.64), and certain chronic diseases including diabetes (1.16, 1.06–1.27), were associated with higher expenditures. Nearby family (0.90, 0.82–0.98) and dementia (0.78, 0.71–0.87) were associated with lower expenditures and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (1.09, 1.06–1.14) and hospitals beds per capita (1.01, 1.00–1.02), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after controlling for regional characteristics. Limitations Decedent sample, proxy informants, large proportion of variation remains unexplained. Conclusions Patient characteristics: functional decline, race/ethnicity, chronic disease, and nearby family, are important determinants of expenditures at end-of-life, independent of regional characteristics.

This study represents the most recent estimate to date of the prevalence of hospital palliative care in the United States. There is wide geographic variation in access to palliative care services although factors predicting hospital palliative care have not changed since 2005. Overall, medical students have high rates of access to hospital palliative care although complete penetration into academic settings has not occurred. The association between hospital palliative care penetration and lower Medicare costs is intriguing and deserving of further study.

Purpose Patients with cancer represent the largest diagnostic group of hospice users, with 560,000 referred for hospice in 2008. Oncologists rely on hospice teams to provide care for patients who have completed disease-directed treatment and desire to remain at home. However, 11% to 15% of hospice users disenroll from hospice, and little is known about their health care use and Medicare expenditures. Patients and Methods We used Surveillance, Epidemiology and End Results–Medicare data for hospice users who died as a result of cancer between 1998 and 2002 (N = 90,826) to compare rates of hospitalization, emergency department, and intensive care unit admission and hospital death for hospice disenrollees and those who remained with hospice until death. We also compared per-day and total Medicare expenditures across the two groups. Results Patients with cancer who disenrolled from hospice were more likely to be hospitalized (39.8% v 1.6%; P < .001), more likely to be admitted to the emergency department (33.9% v 3.1%; P < .001) or intensive care unit (5.7% v 0.1%; P < .001), and more likely to die in the hospital (9.6% v 0.2%; P < .001). Patients who disenrolled from hospice died a median of 24 days following disenrollment, suggesting that the reason for hospice disenrollment was not improved health. In multivariable analyses, hospice disenrollees incurred higher per-day Medicare expenditures than patients who remained with hospice until death (higher per-day expenditures of $124; P < .001). Conclusion Hospice disenrollment is a marker for higher health care use and expenditures for care. Strategies to manage a patient's care and support family caregivers following hospice disenrollment may be beneficial and should be explored.

Objectives To examine patient and regional factors associated with the use of intensive medical procedures in the last six months of life. Design Retrospective cohort study. Setting The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of older adults. Participants 3,069 HRS decedents aged 66 years or older. Measurements Multivariable logistic regression was used to evaluate associations among patient and regional factors and receipt of five intensive procedures: intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, or cardiopulmonary resuscitation in the last 6 months of life. Results Approximately 18% of subjects (n=546) underwent at least one intensive procedure in the last six months of life. Characteristics significantly associated with lower odds of an intensive procedure included age 85–94 years, compared to 65–74 years (Adjusted Odds Ratio 0.67, 95% Confidence Interval 0.51–0.90); Alzheimer’s disease (0.71, 0.54–0.94); cancer (0.60, 0.43–0.85); nursing home residence (0.70, 0.50–0.97); and having an advance directive (0.71, 0.57–0.89). In contrast, living in a region with higher hospital care intensity and black race both doubled one’s odds of undergoing an intensive procedure (2.16, 1.48–3.13, and 2.02, 1.52–2.69, respectively). Conclusion Both patient characteristics and regional practice patterns are important determinants of intensive procedure use in the last six months of life. The effect of non-clinical factors highlights the need to better align treatments with patient preferences.

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Recent growth in the hospice industry has resulted in widespread geographic access to hospice care in the United States, although state and community level variation exists. Future research regarding variation and disparities in hospice use should focus on barriers other than geographic proximity to a hospice.