Hospice Use, Hospitalization, and Medicare Spending at the End of Life

Abstract

The Medicare hospice benefit is associated with reduced hospital care at the end of life and reduced Medicare expenditures for most enrollees. Policies that encourage timely initiation of hospice and discourage extremely short stays could increase these successes while maintaining program goals.

Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis

“…While prior studies among patients with ESRD have described strong associations between hospice referral and healthcare utilization 11,37 and Medicare costs, 37 we found that, consistent with prior literature in other patient populations, 12,39–43 these associations are heavily contingent on the time spent in hospice and the specific measures examined. We found that longer lengths of stay in hospice were generally associated with lower health care utilization and costs – being in hospice for more than two weeks was associated with markedly lower hospital and ICU admission rates, even just 4–7 days of hospice was associated with much lower Medicare costs and rates of intensive procedures, and even very short stays in hospice were associated with markedly lower rates of death in the hospital.…”

“…5 Almost two-thirds (65%) of hospice users in our study received a week or less of hospice care, compared with 39%, 36%, and 34% reported for Medicare hospice beneficiaries with heart failure, colorectal cancer, and dementia, respectively. 39 This is concerning because short hospice stays have been associated with inadequate pain control and unmet emotional needs. 6,7 …”

“…48–50 Nevertheless, hospice referral among members of our cohort who had been on hemodialysis appears to occur much later in the course of illness than for those with other forms of organ failure (e.g., heart failure and chronic lung disease) characterized by a similar degree of prognostic uncertainty. 39 …”

Costs at the End of Life

“…Originally oriented primarily toward cancer patients when implemented in 1982, Medicare hospice is now used by patients with a diverse set of diseases-including dementia, heart failure, and respiratory problems-that have less certain prognoses as well as waxing and waning symptoms that can be hard to manage. With some exceptions (eg, dementia patients residing in nursing homes), use of hospice is associated with lower costs near the end of life by reducing hospitalizations and likely delivering care that is both more goal-concordant and cost-effective [10]. Two Medicare requirements-that persons must (1) be identified by their physicians as having a life expectancy of less than 6 months and (2) forgo acute care services to receive hospice services-have long been perceived as reducing the willingness of both providers and patients to initiate or continue hospice care.…”

Clinical implications and quality of evidence in metaanalysis about effects of palliative care in critically ill patients in the intensive care unit

“…These findings may be explained by increased home care or nursing home referrals in critically ill Medicare patients, which results in more deaths outside of the hospital (Teno et al, 2013;Yoo et al, 2013). Further, the recent increase in completion of advance directives among the elderly might have increased the number of deaths outside the hospital (Silveira et al, 2014;Yoo et al, 2013).Two recent national Medicare studies revealed that earlier hospice enrollment can reduce hospital LOS (Zuckerman et al, 2016) and save on costs (Kelley et al, 2013) until death. In spite of these data, a recent Hartford Foundation report showed that less than 20% of primary care physicians discuss advance directives with patients and bill this discussion to Medicare (The John A. Hartford Foundation, 2016).…”