WaPo had a story on Dec 27, 2013Â with a nearly irresistible click baitÂ 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?Â 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 thatÂ Medicare covering hospice in 1982Â transformed a renegade movement into a big business. However,Â 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 theÂ 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.Â 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 asÂ 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 theÂ lack of a coherent Long Term Care (LTC) systemÂ in the U.S. puts pressure on Medicare benefits like hospice and home health.Â As MEDPAC notes, the most rapidly increasing length of stays under hospice are for non-Cancer diagnoses like Dementia (under Neurology in table below).
For a subset of patients, the hospice benefit may essentially be morphing into a backdoorÂ LTCÂ 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 hospiceÂ benefit needs to be updatedÂ 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.Â 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