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The Value Of Hospice Care: An Interview With Dr. Ziad Obermeyer

Critically ill patients enrolled in hospice programs are far less likely to opt for costly, often unnecessary invasive procedures and die in hospitals, according to an extensive new study led by Dr. Ziad Obermeyer, an emergency medicine physician at Brigham & Women’s Hospital.

Obermeyer studied thousands of hospice and non-hospice patients using a nationally representative sampling of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (brain, pancreatic, metastatic malignancies) enrolled in hospice care before death were matched to an equal number of similar patients who died without hospice support. Median hospice stay was short, only 11 days, but the benefits were extensive.

The average costs of care for patients in their last year of life in the non-hospice group was about $72,000, compared to $63,000 for those enrolled in hospice; the savings totaled nearly $9,000. The study also revealed a huge disparity: 74 percent of patients in the non-hospice group died in a hospital or nursing home, compared to just 14 percent of hospice patients. The findings were published in the Journal of the American Medical Association.

Obermeyer spoke with Life Matters Media about the importance of end of life care, Medicare spending and for-profit hospice programs.

Dr. Ziad Obermeyer
Dr. Ziad Obermeyer

What got you interested in studying the benefits of hospice?

I work in an emergency department in Boston which is the primary locus of care for a major cancer center. I see patients just like those I describe in the study, and I am often the first person to ask them about what kind of care they want at the end of life. When I do it, I’m in a situation where people have only hours to decide difficult things, like whether they want to be on a ventilator or in the intensive care unit.

One of the big motivations for doing this study was dissatisfaction. We are not having enough of these conversations earlier, and we need to do a better job at figuring out what patients really want.

 Why is hospice care often overlooked by seriously ill patients and physicians?

Largely, the kinds of rules insurance companies have often discourage people from accessing end of life care. For example, Medicare does not reimburse providers for discussing end of life care with patients, although they may be changing that rule. Many insurers also require patients to give up any potential curative treatments to start receiving the hospice benefit. There are policy obstacles.

Another reason is that many patients have not made their plans for end of life care known.

Why is it so difficult for physicians to engage in meaningful end of life discussion with patients nearing death?

We know a lot of things about how physicians behave, and they respond to incentives. Currently, physicians are discouraged against having these discussions, because they have to take time from things that are reimbursed, and these conversations are also really difficult to have.

It’s really important to remove all the administrative barriers to having these discussions, and incentivize doctors to bring it up. On the other side, we also have to incentivize patients to ask their doctors about end of life care options.

In an accompanying editorial to your study, Dr. Joan Teno warns about the profit motive of some newer, for-profit hospice programs. What do you think about her concerns?

I take what Dr. Teno says very seriously. I think that a lot of the differences between the for-profit and nonprofit hospices are in care for conditions other than cancer, outside of the specific scope of our study. With metastatic cancer, the prognosis, or trajectory, is much clearer than for some other conditions, like dementia.

Some of the work around how for-profit hospices enroll patients with dementia is concerning, and when you see higher rates of people being discharged from hospice alive, a lot of that is because the prognosis was less certain. But, some of that is certainly fraud. I think Medicare has been particularly aggressive, and appropriately so, in pursuing fraudulent use of hospice.

One of the big motivations for doing this study was dissatisfaction. We are not having enough of these conversations earlier, and we need to do a better job at figuring out what patients really want.

I also think the overriding attention on for-profit hospices detracts from the bigger problem, which is that hospice is underutilized. Yes, there are some fraudulent activities that need to be prosecuted, but the overriding focus on fraudulent activities has come at the expense of promoting hospice use among people who do need it.

Your study also revealed this disparity: 74 percent of patients in the non-hospice group died in a hospital or nursing home, compared to just 14 percent of hospice patients. What do you make of this?

When you look at the medical substance of what the non-hospice group was getting, they were cycling in-and-out of ICUs for acute conditions like heart attacks, kidney failure and infections. Those are absolutely things that happen late in life for people with metastatic cancer, and if you have a very aggressive approach to treating these conditions, you will end up in the hospital and the ICU. That’s probably not the kind of care that most people want at the end of life.

Your study also found $9,000 was saved per patient in hospice. How could these savings impact costs of health care nationally?

We are working on some calculations that would scale these savings up to the national level. Based on our back-of-the-envelope calculations, the total amount of money saved could be in the billions of dollars.

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