Hospice Care Achieving Its Goals with Medicare
Study finds Lower Rate of Hospitalization, ICU
Admission, Invasive Procedures and Costs, plus patient and family
11, 2014 – Hospice care has not clearly carved out its role in
healthcare, although a new study shows it is achieving the goals many
envisioned - significantly lower rates of hospitalization, intensive
care unit (ICU) admissions and invasive procedures at the end of life,
along with significantly lower health care expenditures during the last
year of life.
This research included Medicare patients with
deadly cancers - brain, pancreatic, metastatic malignancies – who
received hospice care, according to a study in the November 12 issue of
Multiple studies have documented the high intensity
of medical care at the end of life, and there is increasing consensus
that such care may produce poor outcomes and conflict with patient
The Institute of Medicine report Dying in America
has drawn attention to the difficulties of promoting palliative care,
including Medicare’s hospice program, the largest palliative care
intervention in the United States, which covers all comfort-oriented
care related to terminal illnesses from medications to home care to
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, according to background
information in the article.
Ziad Obermeyer, M.D., M.Phil., of Brigham and
Women’s Hospital and Harvard Medical School, Boston, and colleagues
matched those enrolled in hospice before death to those who died without
hospice care and compared utilization and costs at the end of life. The
study included a nationally representative 20 percent sample of Medicare
fee-for-service beneficiaries who died in 2011.
Among 86,851 patients with poor-prognosis cancers,
51,924 (60 percent) entered hospice before death. Matching patients
based on various criteria produced a hospice and nonhospice group, each
with 18,165 patients. Median hospice duration was 11 days.
The researchers found that nonhospice beneficiaries
had significantly greater health care utilization, largely for acute
conditions not directly related to cancer and higher overall costs.
Higher for nonhospice
beneficiaries compared to hospice patients were -
>> rates of hospitalizations (65 percent vs 42 percent),
>> ICU admissions (36 percent vs 15 percent),
>> invasive procedures (51 percent vs 27 percent), and
>> death in a hospital or nursing facility (74 percent vs 14 percent).
Overall, costs during the last year of life were
$62,819 for hospice beneficiaries and $71,517 for nonhospice
“Our findings highlight the potential importance of
frank discussions between physicians and patients about the realities of
care at the end of life, an issue of particular importance as the
Medicare administration weighs decisions around reimbursing physicians
for advance care planning,” the authors write.
This work was supported by grants from the National
Institutes of Health, National Cancer Institute, and Agency for
Healthcare Research and Quality.
Editorial: Quality and Costs of End-of-Life Care
Joan M. Teno, M.D., M.S., and Pedro L. Gozalo,
Ph.D., of the Brown University School of Public Health, Providence,
R.I., comment on end-of-life care in an accompanying editorial.
“As financial incentives change in the U.S. health
care system, valid measures of care quality are increasingly important
for ensuring transparency and accountability. Obermeyer and colleagues
assessed hospitalization rates, intensive care admissions, and invasive
procedures, but additional measures must have evidence of their ability
to discriminate the quality of care and must be responsive to change,
easy to understand, and actionable.
"This will involve investing public dollars in the
‘quality’ of quality measures and their dissemination. If quality of
care is not front and center, the momentum to improve end-of-life care
in the United States could face a serious setback.”
Dr. Teno is the recipient of a Robert Wood Johnson
Foundation Health Policy Investigators Award grant.
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