Hospice Care
Increasing But Cost of Dying Still Very Costly for Medicare
Almost 42% of
those who died in U.S. last year were in hospice care; 83% of those were
senior citizens covered by Medicare
Oct. 11, 2010
Statistics show the use of hospice care for the dying is clearly
increasing in the U.S. but does not appear to be reducing the cost of
treatment in the final months of life. Two studies released online today
and a new study from the National Hospice and Palliative Care
Organization show end-of-life hospice treatment
a growing choice but dying is still costly to Medicare.
Medicare paid
for over 83 percent of all hospice care in 2009.
An estimated
41.6 percent of all people who died in the U.S. last year were under the
care of a hospice program, reports the NHPCO. That is up from 38.8
percent in 2008 and 35 percent in 2007.
But a study of heart failure
patients published online today by the Archives of Internal Medicine
finds health care in the last six months of life has become
progressively more expensive for Medicare.
A second online
report finds more men dying of prostate cancer are receiving hospice
care, but that the timing of hospice referral remains poor. Both
articles will be published in the February 14 issue of AIM, which
is one of the JAMA/Archives journals.
"Provision of
high-quality health care at the end of life poses challenges for both
health care providers and policy makers," the authors write.
"End-of-life
care has many dimensions, including patient preferences and values,
health care provider practices and concerns about the appropriate use of
resources. Although most patients prefer to die at home, many die in
hospitals or nursing homes, according to the report of heart failure
patients.
The cost of
health care at the end of life is also substantial. More than
one-quarter of Medicare spending occurs in the last year of life, a
figure that has remained stable for several decades."
Kathleen T.
Unroe, M.D., M.H.A., of Duke Clinical Research Institute, Durham, N.C.,
and colleagues studied 229,543 Medicare beneficiaries with heart failure
who died between 2000 and 2007. They examined resource use in the last
six months of life and calculated costs to Medicare.
Over the entire
study period, about 80 percent of patients were hospitalized in the last
six months of life. Between 2000 and 2007, days in the intensive care
unit increased from 3.5 to 4.6, hospice use increased from 19 percent to
nearly 40 percent of patients and unadjusted average costs to Medicare
per patient increased 26 percent from $28,766 to $36,216.
After adjusting
for age, sex, race, co-occurring medical conditions and region, costs
increased by 11 percent.
Older patients
tended to have lower costs, while those with kidney disease, lung
disease or who were black were more likely to have higher costs.
The trend of
increasing hospice use marks a substantial change in end-of-life care,
the authors note. "Some studies have found hospice care to be more
cost-effective than nonhospice care, but we did not observe lower use of
other services as the use of hospice increased," they write.
"Rates of
inpatient hospitalization remained high, suggesting that the potential
for hospice to prevent costly hospitalizations has yet to be fully
realized."
Heart failure is
a common cause of death in both the United States and Canada, according
to background information in the articles. The condition is listed on
one in eight death certificates in the United States, and the five-year
death rate among those hospitalized with heart failure is about 70
percent.
Fifty-three
percent of prostate cancer patients in hospice
In a second
article, Jonathan Bergman, M.D., of the University of California, Los
Angeles, and colleagues linked data from Surveillance, Epidemiology and
End Results cancer registries to Medicare data to identify 14,521 men
dying of prostate cancer in the United States between 1992 and 2005.
Overall, 7,646
of the men (53 percent) had used hospice, for a median (midpoint) of 24
days. African Americans and those with more co-occurring illnesses were
less likely to use hospice, whereas having a partner and dying more
recently were associated with greater use.
Highlights of
NHPCOs Facts and Figures: Hospice Care in America
Hospice
Participation in Medicare
The Medicare
hospice benefit, enacted by Congress in 1982, is the predominate source
of payment for hospice care.
The percentrage
of hospice patients covered by the Medicare hospeice benefit versus
other payment sources was 83.4% in 2009. The percentage of patient days
covered by Medicare versus other sources was 89%
More findings
for 2009 include:
● 83.0% of
hospice patients were 65 years of age or older
● More than
one-third of hospice patients were 85 years of age or older
● A record
1.56 million people with a life-limiting illness received care from the
nation's hospice providers.
● The average
length of service remained steady at 69 days. Median length of service
was also steady at 21.1 days (that means half of hospice patients
received care for less than three weeks and half received care for more
than three weeks).
● Routine home
care accounted for 95.9 percent of patient care days.
● At 68.8
percent, the majority of hospice care was provided in the home, whether
the patient's home is a private residence, nursing home, or residential
facility.
Findings from
the report are based on data from NHPCO's annual survey, the National
Data Set, and NHPCO membership data. Secondary sources include Medicare
Provider of Services certification data, Medicare hospice cost report
data, state-mandated data submissions and state association membership
surveys.
For more
information about hospice, palliative care, and advance care planning,
visit NHPCO's Caring Connections at caringinfo.org (http://caringinfo.org)
or call the HelpLine at 800-658-8898.
Men who enrolled
in hospice were less likely to receive high-intensity care, including
admission to the intensive care unit, inpatient stays and multiple
emergency department visits.
Although hospice
use increased over time, almost one-third of patients enrolled in
hospice within seven days of death or more than 180 days before dying.
"Hospice stays
shorter than seven days are too brief to maximize the benefit of
enrollment, and individuals making shorter stays receive fewer services
and benefit less from the input of the full interdisciplinary team," the
authors write.
"At the other
end of the spectrum, the Medicare hospice benefit requires that a
primary care physician and a hospice medical director certify that an
individual's expected prognosis does not exceed 180 days when he or she
is enrolled in hospice."
"Increasing
appropriate hospice use may improve the quality of death for men at the
end of life while rationalizing health care expenditures during this
high-cost period," they conclude.
Editorial:
Palliative Care Essential to Properly Treat Patients at the End of Life
"Countries
around the world expend substantial resources to relieve the suffering
caused by the burden of disease," according to Rosemary Gibson, M.Sc.,
author of an accompanying editorial.
"Conversations
that allow the patient to describe what is important as he or she lives
life with serious illness or near life's end should be paramount in
guiding the course of treatment," Ms. Gibson writes.
"High-quality
palliative careprovided in hospitals, nursing homes, at home or in
hospicecan help patients understand their illness and make informed
decisions about their care, together with their families. It must be
integrated into the care of patients in all settings."
"Only with the
explicit goal of relieving the burden of illness, and relieving the
burden of treatment, will health care systems fulfill their intended
purpose of caring for the patient."
Ms. Gibson led the Robert Wood Johnson Foundation's strategy to improve
end-of-life care for more than a decade and is the author of two books.
Cost of Dying,
Particularly in Hospital, Also High in Canada
Another article
published by the journal online reported on the cost of dying among
heart failure patients in Canada.
Padma Kaul,
Ph.D., of the University of Alberta, Edmonton, Alberta, Canada, and
colleagues evaluated data from 33,144 patients in Canada who died of
heart failure between 2000 and 2006. They also assessed resource use in
the last six months of life along with costs to the national health care
system, as Canada has a single-payer system with universal access.
The percentage
of patients who were hospitalized during the last six months of life
decreased over the study period, from 84 percent to 76 percent, as did
the percentage of patients dying in the hospital (from 60 percent to 54
percent).
However,
patients who died in later years were substantially more likely to
receive outpatient care in the last six months of life (52.8 percent in
2000 vs. 69.8 percent in 2006), and the average number of visits among
those receiving such care increased from 6.4 to 7.7.
In 2006, the
average end-of-life cost was $27,983 in Canadian dollars. "Costs in the
last six months of life among patients who died in hospital were more
than double those for patients who did not," $38,279 vs. $15,905, the
authors write.
"The substantial
impact of location of death on costs can be illustrated as follows:
reducing the number of hospital deaths by 10 percent in 2006 would have
saved the health care system approximately $11 million (486 patients
multiplied by mean cost savings of $22,374 per patient)."
"Increasing the
availability of alternative venues of care, such as long-term care and
home care, may be effective in further reducing hospitalizations and
containing costs," they conclude.
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Oct. 11, 2010
Statistics show the use of hospice care for the dying is clearly
increasing in the U.S. but does not appear to be reducing the cost of
treatment in the final months of life. Two studies released online today
and a new study from the National Hospice and Palliative Care
Organization show end-of-life hospice 
