Medicare’s Hospice Benefit: Analysis of Utilization and Resource Use

Bogasky, Susan; Sheingold, Steven H.; Stearns, Sally C.

doi:10.5600/mmrr.004.02.b03

Cited by 11 publications

(13 citation statements)

References 3 publications

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“…Hospice enrollment of 5 to 8 weeks produced the greatest savings; shorter stays produced fewer savings, likely because of both hospice initiation costs, and need for intensive symptom palliation in the days before death. 24 Overall, these results may indicate that efforts to promote broader and earlier hospice uptake are unlikely to produce increases in total costs.…”

Section: Discussionmentioning

confidence: 94%

Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer

Obermeyer

Makar

Abujaber

et al. 2014

JAMA

247

210

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IMPORTANCE More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it. OBJECTIVE To compare utilization and costs of health care for patients with poor-prognosis cancers enrolled in hospice vs similar patients without hospice care. DESIGN, SETTING, AND PARTICIPANTS Matched cohort study of patients in hospice and nonhospice care using a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies) enrolled in hospice before death were matched to similar patients who died without hospice care. EXPOSURES Period between hospice enrollment and death for hospice beneficiaries, and the equivalent period of nonhospice care before death for matched nonhospice patients. MAIN OUTCOMES AND MEASURES Health care utilization including hospitalizations and procedures, place of death, cost trajectories before and after hospice start, and cumulative costs, all during the last year of life. RESULTS Among 86 851 patients with poor-prognosis cancers, median time from first poor-prognosis diagnosis to death was 13 months (interquartile range [IQR], 3–34), and 51 924 (60%) entered hospice before death. Matching yielded a cohort balanced on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization, with 18 165 patients in the hospice group and 18 165 in the nonhospice group. Nonhospice Group (n = 18 165) Hospice Group (n = 18 165) Risk Ratio (95% CI) Hospitalizations, % (95% CI) 65.1 (64.4–65.8) 42.3 (41.5–43.0) 1.5 (1.5–1.6) Intensive care unit admission, % (95% CI) 35.8 (35.1–36.5) 14.8 (14.3–15.3) 2.4 (2.3–2.5) Invasive procedures, % (95% CI) 51.0 (50.3–51.7) 26.7 (26.1–27.4) 1.9 (1.9–2.0) Death in hospital or nursing facility 74.1 (73.5–74.8) 14 (13.5–14.5) 5.3 (5.1–5.5) Costs in last year of life, $ (95% CI) 71 517 (70 543–72 490) 62 819 (62 082–63 557) Difference, 8697 (7560–9835) After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. Nonhospice beneficiaries had significantly greater health care utilization, largely for acute conditions not directly related to cancer and higher overall costs. CONCLUSIONS AND RELEVANCE In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.

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Section: Discussionmentioning

confidence: 94%

Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer

Obermeyer

Makar

Abujaber

et al. 2014

JAMA

247

210

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“…Receiving home hospice and longer length of service are associated with experiencing a live discharge. The relationship between number and timing of nurse visits and live discharge is not well established, although previous studies suggest a nonlinear relationship, with more intensive service utilization at the beginning and end of hospice service …”

mentioning

confidence: 99%

“…We extend previous research by examining the role of hospice service characteristics including hospice location and the timing and quantity of nursing visits, as potentially modifiable factors for this type of live discharge risk among PWD. We explore nursing visits specifically because nurses comprise the largest proportion of hospice professionals and are the professional care team members with the most frequent and regular contact with all hospice patients, following the Medicare‐regulated minimum of one nurse visit every 14 days . Although social workers and chaplains also visit hospice patients, their contact is less regular and differentially distributed Nonreligious patients may not receive chaplain services, social workers’ involvement depends on patient needs for supplementary resources, whereas nurses are well positioned to influence hospice care plans and outcomes.…”

mentioning

confidence: 99%

“…The relationship between number and timing of nurse visits and live discharge is not well established, although previous studies suggest a nonlinear relationship, with more intensive service utilization at the beginning and end of hospice service. 23,24 This study aims to (1) identify demographic and health correlates of live discharge due to condition stabilization in PWD, and (2) explore how hospice service delivery factors relate to this live discharge type in PWD. We focus on live discharge due to condition stabilization because of its particular importance in PWD, 12 whose odds of experiencing this disenrollment type are more than 13 times greater than for patients with cancer.…”

mentioning

confidence: 99%

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Race, Ethnicity, and Other Risks for Live Discharge Among Hospice Patients with Dementia

Luth

Russell

Brody

et al. 2019

J American Geriatrics Society

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OBJECTIVES The end‐of‐life trajectory for persons with dementia is often protracted and difficult to predict, placing these individuals at heightened risk of live discharge from hospice. Risks for live discharge due to condition stabilization or failure to decline among patients with dementia are not well established. Our aim was to identify demographic, health, and hospice service factors associated with live discharge due to condition stabilization or failure to decline among hospice patients with dementia. DESIGN Retrospective cohort study. SETTING A large not‐for‐profit agency in New York City. PARTICIPANTS A total of 2629 hospice patients with dementia age 65 years and older. MEASUREMENTS Primary outcome was live discharge from hospice due to condition stabilization or failure to decline (vs death). Measures include demographic factors (race/ethnicity, Medicaid, sex, age, marital status, parental status), health characteristics (primary dementia diagnosis, comorbidities, functional status, prior hospitalization), and hospice service (location, length of service, number and timing of nurse visits). RESULTS Logistic regression models indicated that compared with white hospice patients with dementia, African American and Hispanic hospice patients with dementia experienced increased risk of live discharge (African American: adjusted odds ratio [aOR] = 2.42; 95% confidence interval [CI] = 1.34‐4.38; Hispanic: aOR = 2.99; 95% CI = 1.81‐4.94). Home hospice (aOR = 7.57; 95% CI = 4.04‐14.18), longer length of service (aOR = 1.04; 95% CI = 1.04‐1.05), and more days between nurse visits and discharge (aOR = 1.86; 95% CI = 1.56‐2.21) were also associated with live discharge. CONCLUSION To avoid burdensome and disruptive transitions out of hospice in patients with dementia, interventions to reduce live discharge due to condition stabilization or failure to decline should be tailored to meet the needs of African American, Hispanic, and home hospice patients. Policies regarding sustained hospice eligibility should account for the variable and protracted end‐of‐life trajectory of patients with dementia. J Am Geriatr Soc 68:551–558, 2020

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“…2 Moreover, fewer than half of Medicare beneficiaries used hospice before death, despite evidence that hospice services improve cancer patients’ quality of life near death and caregivers’ bereavement outcomes. 3–6 ACA-stipulated programs and subsequent efforts were designed to address these deficiencies in access to high-quality end-of-life care. However, important gaps in coverage persist.…”

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confidence: 99%

The Affordable Care Act and End-of-Life Care for Patients With Cancer

Parikh¹,

Wright²

2017

Cancer J

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The Affordable Care Act (ACA) expanded access to high-quality end-of-life care for Americans with serious illness, including cancer. Before the ACA was enacted in 2010, nearly 715,000 patients died in hospitals annually, 1 despite evidence that most Americans prefer to die at home. 2 Moreover, fewer than half of Medicare beneficiaries used hospice before death, despite evidence that hospice services improve cancer patients’ quality of life near death and caregivers’ bereavement outcomes. 3–6 The ACA-stipulated programs and subsequent efforts were designed to address these deficiencies in access to high-quality end-of-life care. However, important gaps in coverage persist. In this article, we highlight the impact of the ACA on end-of-life care for individuals with and without cancer.

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Medicare’s Hospice Benefit: Analysis of Utilization and Resource Use

Cited by 11 publications

References 3 publications

Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer

Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer

Race, Ethnicity, and Other Risks for Live Discharge Among Hospice Patients with Dementia

The Affordable Care Act and End-of-Life Care for Patients With Cancer

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