Medicare Skilled Nursing Appears to Be Used for End
of Life Care Due to Cost
Authors say high Medicare SNF benefit use at the end
of life highlights a need to incorporate quality palliative care
services in nursing home
Oct. 1, 2012 – Most Medicare patients enroll in
skilled nursing facility (SNF) care for rehabilitation or
life-prolonging care, but in reality, many are dying patients discharged
to a SNF for end-of-life care, where the available care may not be
available. A new report finds that almost one-third of Medicare senior
citizens received care in a SNF in the last six months of their lives
under the Medicare post-hospitalization benefit. A reason for this shift
may be the cost.
The report, published Online First by Archives
of Internal Medicine, a JAMA Network publication, says switching
patients from Medicare coverage under the SNF benefit to the hospice
benefit has financial implications for the patient and for the nursing
Unlike the SNF benefit, the hospice benefit does
not pay for room and board, which means patients who transition to the
hospice benefit must pay out of pocket or by enrolling in Medicaid, for
which many patients do not qualify, according to the study background.
The Centers for Medicare and Medicaid Services says
nearly two-thirds of nursing facility residents are enrolled in
Medicaid, and most are also enrolled in Medicare.
To be eligible to elect hospice care under
Medicare, an individual must be entitled to Part A of Medicare and be
certified as being terminally ill. An individual is considered to be
terminally ill if the medical prognosis is that the individual’s life
expectancy is 6 months or less if the illness runs its normal course,
according to the Medicare Benefit Policy Manual, Chapter 9, Coverage of
Hospice Services Under Hospital Insurance
In this new study, Katherine Aragon, M.D., of the
University of California, San Francisco, and colleagues used data from
the Health and Retirement Study, a nationally representative survey of
older adults, linked to Medicare claims (1994 through 2007) to examine
the use of the Medicare post-hospitalization SNF benefit at the end of
The study included 5,163 Medicare participants who
had died at an average age of nearly 83 years.
“Our finding that Medicare decedents commonly used
SNF care at the end of life suggests a need to better understand who is
using the SNF benefit and whether they are receiving care that matches
their goals,” the authors comment.
In total, about 30 percent of the participants had
used the SNF benefit in the last six months of life and about 9 percent
had died while enrolled in the SNF benefit. The use of the SNF benefit
was greater among patients who were 85 or older, had at least a high
school education, did not have cancer, resided in a nursing home, used
home health services and were expected to die soon, according to the
Of the participants who lived in the community and
had used the SNF benefit, about 42 percent died in a nursing home,
nearly 11 percent died at home, nearly 39 percent died in the hospital
and 8 percent died elsewhere.
In contrast, of those participants who lived in the
community but did not use the SNF benefit, about 5 percent died in a
nursing home, almost 41 percent died at home, about 44 percent died in
the hospital and nearly 10 percent died elsewhere, the study results
“Unfortunately, financial issues may contribute to
why patients near the end of life are using the SNF benefit and not the
hospice benefit. Elderly patients living in the community who are
becoming more symptomatic or are functionally declining may be admitted
to the hospital because families cannot manage them at home. Our study
suggests that older, more clinically complex patients are using the SNF
benefit near the end of life,” the authors note.
The authors conclude that high Medicare SNF benefit
use at the end of life highlights the need to incorporate quality
palliative care services in nursing home.
“The hospice benefit is the primary way in which
palliative care services are provided in nursing homes. A growing focus
is on the development of palliative care in nursing homes alongside the
current goals of functional improvement. Perhaps having Medicare pay
concurrently for post-acute SNF care and hospice services for the same
condition could allow earlier incorporation of palliative care for these
medically complex patients,” the authors conclude.
The study was supported in part by grants from the
National Institute on Aging and from the National Center for Research
Resources University of California, San Francisco Clinical and
Translation Science Institute.
Commentary: Aligning Prognosis, Patient Goals,
Policy and Care Models
In an invited commentary, Peter A. Boling, M.D., of
Virginia Commonwealth University, Richmond, writes: “Reflecting on this
study, about half of the SNF users did not die in the nursing home and
ultimately went home, despite having significant frailty. We must all
carefully avoid rushing to judgment and imposing end-of-life care
protocols when reasonable vitality and quality of life remain, despite
chronic illness burden.”
“Continuity of care and the processes required to
resolve complex issues are often fractured in contemporary health care,
resulting in care that is ultimately not what many reasonable persons
would choose,” Boling continues.
“Without doubt, the SNF benefit is too often used
on admission to nursing homes for patients in whom the expected outcome
is death because of incentives for the facility and financial burdens on
the family that come from using the Medicare hospice benefit at the
outset of nursing home care. Clinical practice and health care policy
should perform better in this context, and this ultimately ties back to
alignment of incentives,” Boling concludes.
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