Medicare has long supported specialized end-of-life care for its beneficiaries, including those in nursing homes. Hospice care, which focuses on symptom relief and offers emotional and spiritual support to patients and their families, is generally considered a good thing, and experts recommend that it begin with plenty of time to help prepare for death.
But are Medicare’s payment policies leading to excessively long hospice stays?
Susan Miller, a community health professor at Brown University and an expert in end-of life and long-term care issues, evaluated hospice use in U.S. nursing homes between 1999 and 2006 and found the typical treatment time increased from 46 to 93 days.
Miller also found a 50-percent increase in the number of hospices, primarily for-profit ones, suggesting the payment system might be driving the market.
The study results will appear in the August issue of The Journal of the American Geriatrics Society. Miller answered questions about her findings.
PBN: What led you to look into this issue in particular?
MILLER: Our group has been involved in research concerning hospice and Medicare for years. In the late 1990s, for example, our research helped guide policy for Medicare-funded hospice services. Specifically, studies we conducted showed significantly fewer hospitalizations near the end of life when dying nursing home residents enrolled in hospice. This finding conveyed the strong possibility that hospice enrollment was associated with lower Medicare expenditures (later supported by other research we’ve conducted), and this appeared to motivate policy makers to promote hospice care in nursing homes.
[However], long hospice stays are a concern since the savings realized from reducing end-of-life hospitalizations are fewer as mean hospice stays are longer. We found a direct association between increases in a state’s Medicare-funded hospice use and its increase in hospice providers. Overall, this development is not a bad one, since more people are getting hospice services. However, we wanted to know enough about this increase so that we can provide a balanced response that will prevent a backlash against all Medicare-sponsored hospice care.
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PBN: Do you have a sense of what an optimal length of stay would be?
MILLER: First, Rhode Island is not typical of what we are seeing nationally. In 2006, the average length of a hospice stay in the United States in nursing homes was 93 days; in Rhode Island, it was 69.7. Also, nationally in 2006, 25 percent of Medicare hospice care was provided in nursing homes while in Rhode Island 45 percent was. And 33 percent of persons dying in U.S. nursing homes elected hospice in 2006, but 43 percent in Rhode Island did.
In our study we estimated mean lengths of stay in nursing homes [hospice] to be approximately 20 days longer in nursing homes versus community settings. The issue is prognosis. It is harder to determine a six-month survival time (as required for Medicare hospice eligibility) for persons with chronic terminal illness such as dementia, who more often reside in nursing homes.
There is no optimal time for hospice referral, but stays of at least one month, I believe, are desirable.
PBN: What do you think has driven this sharp increase in lengths of stay?
MILLER: Medicare-certified hospices contract with nursing homes to provide end-of-care to their residents. Individual residents are referred to hospice by their physicians, often at the suggestion of nursing home staff or after family requests. Hospices determine if residents meet eligibility criteria. Hospices get paid directly from Medicare for their care and additionally receive 95 percent of a nursing home’s Medicaid per diem rate [which they then pass on to the nursing home].
We believe there is a direct correlation between some provider behavior and the long lengths of stay. We do not see the increase in hospice to be a bad thing. We also believe that a given proportion of hospice patients will have long lengths of stay that are justified. What does concern us is What does concern us is that the payment system provides a financial incentive for long stays, since there is a flat daily Medicare payment rate paid to hospices for each day a person is enrolled on hospice, even though research has shown hospice care to be more intense at the beginning and end of hospice episodes. Therefore, in the article, we support [a federal] recommendation to change the method for paying hospices.
PBN: What do you think is the proper approach to this problem?
MILLER: We think there should be a tiered payment system in place. Specifically, we recommend that the payment system for hospice reflect the greatest need for payment – at the beginning and the end. Also, as recommended by [the Medicare Payment Advisory Commission], we agree that a visit by a physician or nurse practitioner occur prior to recertifying a hospice patient as continuing to be eligible for hospice.
PBN: What else should Centers for Medicare & Medicaid Services be doing to maximize the benefits of hospice care for Medicare beneficiaries while also controlling costs?
MILLER:First, there should be more frequent government survey of Medicare hospices. Right now, once a new hospice becomes a certified Medicare provider, it is only required to be resurveyed every eight to 10 years. A lot can happen in 10 years, and a lot of poor care can be provided.
Also, a huge issue is that nursing home residents receiving Medicare Part A-funded skilled nursing home care cannot simultaneously access hospice. Residents on such care are often dying and are less likely to forgo the nursing care benefit to choose hospice until the benefit has expired. Many hospices, including Home and Hospice Care of Rhode Island, provide palliative care consultations to assist with symptom management, but that is not the full hospice benefit. A hospice/palliative care benefit for those residents is needed. I believe access to such care would improve end-of-life care and reduce Medicare expenditures.
To restate, the national average length for hospice services for a nursing home resident is 93 days, but in Rhode Island it’s only 70. The Medicare hospice benefit covers six months. Does anyone think 70 days out of 180 days available is a problem?
Only 43% of dying patients in R.I. nursing homes elect hospice care. While that’s better than the national average of 33% (and merits praise to our state’s nursing homes, which refer patients to hospice care even though it costs them 5% of their payment to do so), it still seems too little. Hospice care is a kindness to patients who are dying of dementia, and I think it would be wonderful to see that percentage increase.