WaPo Story on Medicare Hospice Benefit

WaPo had a story on Dec 27, 2013 with a nearly irresistible click bait  headline “Hospice firms draining billions from Medicare.” Like much health policy that focuses on the end-of-life, the story raises some valid points, but gives in to the sensational and turns away from the far more difficult reality of the counterfactual: current hospice policy as compared to what?

Medicare policy is inextricably end-of-life policy due to the fact that more than 80% of the people who die each year in the United States are insured by the Medicare program. That is because Medicare insures virtually all persons age 65 and older, and everyone eventually dies.What care should the elderly receive? Does care increase life span? Does it improve quality of life? How much does it cost? Who should decide if the intersection of these questions are worth it? These are very difficult questions to answer. Our country cannot even bear to ask them. So, we look for examples of malfeasance being the problem, in large part because as long as we focus there we don’t have to stare at that set of questions above and imagine our mother, wife, brother or ourselves being the one about whom the questions are posed.

I very much agree with the WaPo story that Medicare covering hospice in 1982 transformed a renegade movement into a big business. However, recent work has demonstrated that hospice reduces Medicare costs as compared to what they would have been under normal care, and that is including the tail of long-stay, high hospice expenditure patients. That does not mean that inappropriate utilization of hospice should be tolerated, but demonstrates that most of the policy focus is on long stay hospice, ignoring the short stay issues. To wit, in the WaPo story:

The average length of a stay in hospice care also jumped substantially over that time [Don’s insert: 2000-2012], in California and nationally, according to the analysis.

This is true, but incomplete. From the 2013 MEDPAC chapter on hospice (p. 261-62):

In 2011, 45.2 percent of Medicare beneficiaries who died that year used hospice, up from 44.0 percent in 2010 and 22.9 percent in 2000. Average length of stay among decedents, which grew between 2000 and 2010 from 54 days to 86 days, held steady at 86 days in 2011. The median length of stay during the same years remained stable at approximately 17 or 18 days.

Mean length of stay has risen, while the median has stayed about the same. Half of the Medicare beneficiaries using hospice do so for less than 3 weeks, and the 25th percentile stay (the period of time that 1 in 4 Medicare hospice users use the benefit) has been around 5 days for 15 years (see page 271-72).

Long hospice stays pose policy problems, but so too do short ones. Those using hospice for what amounts to a long weekend prior to death mean that patients are not receiving the full benefits they might from hospice, as well as foregone cost savings that Medicare could have realized has hospice been elected earlier. So while some patients need to use hospice less, far more likely would benefit from using it longer before death, yet this side of the hospice equation is not even mentioned in the WaPo story. And in fairness to the WaPo reporters, MEDPAC has focused on the long stay issue the past few years as well.

A part of this story that is easy to miss is that the lack of a coherent Long Term Care (LTC) system in the U.S. puts pressure on Medicare benefits like hospice and home health. As MEDPAC notes, the most rapidly increasing length of stays under hospice are for non-Cancer diagnoses like Dementia (under Neurology in table below).

ScreenHunter_02 Dec. 27 11.58

For a subset of patients, the hospice benefit may essentially be morphing into a backdoor LTC benefit, with the incentives of some hospices aligning with those of family members desperate to provide a home based care solution for a loved one with a serious illness that may not be terminal per the hospice benefit’s definition. This is a sign that the Medicare benefit package does not meet the needs of some of its beneficiaries. We at Duke have recently completed some work asking seriously ill patients what Medicare benefits would be most important to them if they couldn’t have everything; I am desperate to blog about the findings, but must wait until we get the main paper accepted by a medical journal, hopefully early in 2014. However, the persons most directly affected (patients) are ready for this conversation.

There are plenty of signs that the Medicare hospice benefit needs to be updated and modernized, preferably toward a concurrent care model. Long lengths of stay are just one. And the bright lights should not only be shone on hospice in the search for wasteful spending. As I wrote in Health Affairs blog back in May, 2013:

But all of the therapies available to chronically ill Medicare beneficiaries with life limiting illnesses should be subjected to similar scrutiny, not just hospice. Does it extend life? Does it improve quality of life? How much does it cost? Is it worth it?

The problem is not that some question the value of hospice under certain circumstances in which it is currently being used in the Medicare program. The problem is that hospice appears to be the only part of the Medicare benefit subjected to such scrutiny.

cross posted at freeforall

Author: Don Taylor

Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.

13 thoughts on “WaPo Story on Medicare Hospice Benefit”

  1. In the years I was a hospice volunteer, I saw many patients overtreated in the medical system far after any hope of cure had passed because the financial incentives were to continue the treatment until the brink of death. These patients would then be dumped at the last minute into hospice, their families would endure a transition to another care team and the patient would die almost immediately without getting the “good death” that hospice can help provide. There were several times when I would get a call that I had a new patient, call the family that same day to schedule a first visit and find out that the patient was already dead.

    So I agree with Don that it is wrong to treat shorter as a proxy for better in hospice. More generally, I was disappointed that the Washington Post story put so much emphasis on cost relative to the patient’s experience of dying and the long-term impact of the nature of the death (screaming in pain in a hospital/nursing home versus dying peacefully at home alongside loved ones) on the family.

    1. There are still physicians who practice this way, Keith. My mother-in-law’s primary care provider strongly and vocally disapproved of our seeking hospice care for her. I learned later that she dislikes hospice care because her patients typically come into hospice and die within 48 hrs of arrival.

      1. she dislikes hospice care because her patients typically come into hospice and die within 48 hrs of arrival.

        This makes me sad and rather angry and also incredibly grateful that she wasn’t my mom’s doctor.

        Mom died 4 weeks ago, at home under hospice care. She lived less than a week after we brought her home and that was a good thing, not a problem. I am so glad that all of mom’s doctors (2 at the hospital and her GP, who was technically responsible for her care once she was released from the hospital) were all incredibly supportive of hospice. Mom had acute leukemia which had progressed to the point of destroying her immune system, leaving her with no way to fight the multiple infections that she had. There was nothing that the hospital could do for her that wouldn’t have simply prolonged the misery and she did not want to be there. She really didn’t want to die in a nursing home either. Had it not been for hospice and the fact that mom’s Medicare paid for all of it, we would not have been able to honor her wishes. With hospice support she was able to be at home and surrounded by family and close friends and to have a peaceful death with very little pain. As a bonus, those last days of care at home cost a fraction of what it would have cost to keep her in the hospital or a nursing facility.

        1. I’m sorry for your loss, but I’m glad your circumstances allowed her to come home. We didn’t have that option: Mom needed someone with her on a full-time basis. I was it as far as local family were concerned, and I had my own job to tend. If my wife had been local, we could have worked out something that brought her into our home with hospice support.

          And yes, I was pretty angry: angry enough that after we had the immediate matters taken care of I made an appointment to meet her physician and their risk-management guy. I don’t think it ran to the level of malpractice, even if it had I’m not sure I would have done anything. But I did tell her just what I thought of the care she provided.

    2. Keith
      I did not know you had this experience. We need a top to bottom modernization of the Medicare hospice benefit, but the politics (the death panel nonsense, etc) have taken what used to be a bipartisan issue and made it toxic.

  2. May be worth noting that the British health care system ha also failed to find a solution to the long-term care problem that satisfies the many interests involved. Making LTC care free under the NHS would amount to a huge subsidy to heirs; the practical question is whether the invalid elderly should be expected to sell, or at least draw down the equity in, their homes before becoming entitled to free care at the end of their lives.

    Strikingly, although the great and saintly Cicely Saunders invented modern hospice care in Britain, hospices are not integrated into the NHS but funded independently as charities. (So are lifeboats, a public service in the narrowest of night-watchman states.) The palliative care consultants attached to British hospices are, in my limited experience, sometimes on the NHS payroll, so it’s not a clear-cut separation. But charitable funding seems to prevent mission creep.

    Some British hospices also offer residential outreach, a valuable option.

  3. There is no question that something is messed up in the relationship between Medicare and hospice providers.

    My mother-in-law died of lung cancer a bit more than a year ago now. Before the diagnosis, she lived alone with her cats. I lived in the same city, my wife lived about 1000 miles away. When she was diagnosed, she had suffered a fall and was hospitalized. The cancer was found when they were searching for the cause of her back pain.

    She declined chemotherapy. She could not stay in the acute care hospital, and her life expectancy was measured in weeks. (In the event, days were the right measure.) We tried to get her admitted to our local (not-for-profit) hospice. Although she could be admitted, her insurance (BC-BS Medicare supplement) and Medicare would not pay for her stay there. They would cover hospice care at home, but she needed round-the-clock care to be sent home. I couldn’t be there,

    They would, however, pay for her to be admitted to a skilled nursing facility (SNF) for rehab care. So that was where she went. They did a decent job of controlling her pain, but she had to receive rehab therapy she didn’t want or need. The physical surroundings at the hospice were nicer, more home-like than the rooms at the SNF.

    So, the bottom line: Medicare paid for more expensive care that she didn’t need for reasons that have still not been explained to us. Something is broken, but I don’t know what to suggest to fix it.

    1. Dennis
      I am sorry for your experience….it should not have been that way. Esp odd is admission to SNF for rehab given hospice eligible. The only thing I can think of is that a given hospice would not undertake home based hospice due to lack of full time caregiver present if needed….the part I don’t follow is why admission to inpatient hospice not allowed if SNF ok.

      1. Well, this is a necessary farce non-rich, seniors are compelled to participate in. The dance goes like this:

        The sick elder is in a traditional hospital for some illness, disease, or injury, (getting old stuff) and, after the hospital has done all the daily treatment/care it can dispense, and the patient has progressed to the point where no more improvement can be expected from the traditional hospital, it wants the senior “out.” And, here I give the hospitals I’ve had experience with some credit for the humanity they show in exiting the patient. Knowing that our country simply has not dealt with the reality of people getting old, sick, and dying, they know that “out” means a skilled nursing home, or their children’s home, which few average people can afford, or handle. So, the hospital pretends, and certifies, that it has done its part in the patient’s “road to recovery” (ahem) and all he/she needs now is 90 days in a “rehab” skilled nursing home to be as good as new again. It’s not considered long term nursing home care, rather it’s an extension of the original care given at the traditional hospital. Medicare pays for one, not the other.

        Personally, I was pleasantly surprised, and grateful, that hospital administrators thought up this scheme in lieu of our government’s paralysis, or denial, of this dilemma we all face, or, will face. But, wait, there’s more.
        Since almost every average family has to, eventually, deal with this situation, parents getting too old to care for themselves, and, having to decide between the only two choices available to them, American ingenuity came to the rescue. BTW, the two choices are: declaring indigence, and having Medicaid pay for long term care. And, they are very, very strict, and know all the tricks of transferring wealth. No one recommends trying to fool the authorities. Or, the second choice is simply paying out-of pocket for long term care. Anybody even tangentially aware of nursing home costs knows that if the senior lives more than a couple of months, you’re talking hundreds of thousands of dollars, or more. As you can see, and those who went before you have seen, neither option is good, or, even possible for most normal, average folks.

        Now, remember, I said, “wait, there’s more?” God bless’m, they figured out a third way. After the elder has had his/her original hospital stay, then 90 days of “rehab,” it’s time for the children to face the music. Now here’s the trick; they only have to “face the music” for 30 days (I believe,) then elder, mom/dad gets a mysterious abdominal irritation. Back to the hospital we go; of course, it takes two days to diagnose the tummy ache (the legal minimum hospital stay requirement) and, yup, you guessed it, back to the good ole nursing home for another 90 days more of that good ole “rehab.”

        And, please believe me, I have seen this merry go round go on for a year, or, even longer. And, I’m sure someone will point out to me why it’s so terribly wrong, but, with so few choices (all bad) what’s the alternative? Please don’t say, “save for your retirement.” In America, circa 2014, with too many seniors living on, mostly, social security, I’d like to hear a realistic alternative.

        1. Brief comment from the care-giving trenches….

          I think you get only 120 rehab days from medicare, then after those are gone, individual must be out of skilled nursing facility (SNF) and hospital for 60 days before she/he gets another 120 days. In Fla at least, that’s the way it works. One could have an additional 30 days after the 3 day hospital stay to diagnose tummy ache but not 120 as you state unless the 90 days of rehab was delivered to home (or ALF facility, which IS home at that point).

          However, if rehab took place at rehab facility (SNF), then patient must have 60 days absence from hospital and SNF to get rehab more days when the 120 are used up. So in your scenario, mom/dad gets the 30 remaining days and then it’s private pay until 60 “carefree” (in the sense of needing no care!) days pass. If the individual is sick and declining, how does she/he go 60 days without needing care?

          And it’s not like Part B (PT, OT, ST) benefits, which get renewed every calendar year.

          I agree totally with the post and most comments here. I particularly agree with this:
          These are very difficult questions to answer. Our country cannot even bear to ask them. So, we look for examples of malfeasance being the problem, in large part because as long as we focus there we don’t have to stare at that set of questions above and imagine our mother, wife, brother or ourselves being the one about whom the questions are posed.

          My mother and father are both looking at long term medicaid “qualification”. However, they did not have to become impoverished. An attorney has preserved their assets so that their children can expend them on the various services items that are not provided by SNF. I never knew about any of this until my father’s dementia basically mandated LTC.

          To hear that NHS is struggling with this confirms the obvious to anyone paying attention (like I am now): the current solutions are not working and we MUST figure out something better. SOON. And I don’t think robots are the answer. Sick people need human touch and interaction. SNFs suck out the soul.

          1. Good post, Don Taylor.
            Excellent comments all….

            Of course these are difficult questions. In the olden days, the olden were just allowed to die off or were assisted to their end in a variety of the ways of home based neglect. The fact that this is becoming a “question” is to our credit. Let’s hope we find a way to answer them humanely now that they are sometimes asked.

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