End-of-life care is expensive and has become controversial. Patient often don’t understand the choices or that there are choices, doctors aren’t always good at being straight with patients about the reality of their situation and so patient preferences aren’t always understood or followed. For nursing home residents the situation can be even worse, as they often have dementia or cognitive issues and may or may not have family or others who can function as surrogate decision-makers. Hospice has become a good end-of-life alternative for many patients, including nursing home residents. A study in the New England Journal of Medicine looks at the impact on Medicare of expanding hospice use by such residents. (NEJM Article) One purported benefit of hospice care is that it reduces often futile end-of-life spending. The study found that while the percent of Medicare beneficiaries using hospice rose dramatically in the last decade, so did spending. Hospice providers have been known to game the system to maximize reimbursement, and the Office of Inspector General has expressed concern that this may be happening with nursing home patients.
The researchers studied hospice use patterns and overall costs between matched groups of patients who died in 2004 and 2009. They looked at expenditures in the last year of life as the main variable. Average stay in hospice for these residents increased from 72 days in 2004 to 93 days in 2009. In both years the primary diagnosis was dementia. Compared to non-hospice users prior to death in 2004, non-hospice users in 2009 had an average $3143 increase in last year of life spending, but hospice users had a $9906 increase, three times as much. While those in hospice had some reduction in hospitalizations and other care, the costs of their hospice stay far outweighed those savings. They did have less aggressive care, for example, fewer ICU admissions, which generally increases quality of life. We often want to believe that less aggressive end-of-life care not only improves quality, but will save money. That is not the case here. Hospice may have been better for the patients but it added a lot to Medicare spending. This may be a looming target for payment reform.