Hospice care becoming costlier, less aggressive, study finds

Brown University researchers have concluded that hospice care for nursing home residents is becoming more prevalent — and more expensive — despite less aggressive life-sustaining measures.

The research is consistent with an earlier Brown University study that concluded nursing home caregivers well-versed in palliative care tend to focus less on possibly futile “aggressive” life-saving measures.

The study was published in Thursday's New England Journal of Medicine and funded by the Centers for Medicare & Medicaid Services and the National Institute on Aging.

Medicare initially created its hospice benefit in 1983 and expanded it in 2004 as a flat per-day payment to reflect the growing acceptance of hospice care, Pedro Gozalo, Ph.D., a research associate professor of health services, policy and practice at Brown University School of Public Health, told HealthDay.

In their latest study, Brown researchers examined the change in last-year-of-life Medicare expenditures during the most recent expansion of the program that began in 2004 and continued through 2009. The team also examined intensive care unit use in the last 30 days of life and, for patients with advanced dementia, feeding tube use and hospital transfers within the last 90 days of life.

What they found could seem inexplicable to many. Of the more than 780,000 nursing home decedents, about 28% had elected to use hospice care in 2004. That percentage jumped to about 40% by 2009.

During that time period, the mean net-increase of Medicare expenditures per person rose $6,761, yet treatment measures considered to be aggressively tapered off. Those included significant decreases in hospital transfer rates, feeding tube use and ICU admissions.

The mean length of stay in hospice during that period, meanwhile, increased from 72.1 days in 2004 to 92.6 days in 2009. Such a phenomenon is not lost on CMS, which raised questions about overall hospice costs when it announced this week a sweeping proposal establishing payment tiers based on length of stay and laying the groundwork for additional quality reporting measures. 

Despite the promise of higher payments in the coming year, CMS investigators argued that since hospice is most profitable during the long, low-cost middle portions of an “episode,” longer episodes would potentially have very profitable, long middle segments.

Earlier this year, the National Right to Life Committee issued a lengthy report on advanced care planning, raising concerns that some overzealous caregivers may be skipping life-preserving treatment because they are “motivated by cost concerns, promotion of advance directives and advance care planning.”