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Hospice Leads To Better Care, Lower Costs At End Of Life: JAMA

Clinicians in ICU. Courtesy WikiMedia Commons.
Clinicians in ICU. Courtesy WikiMedia Commons.

Terminally ill patients enrolled in hospice care have lower rates of hospitalization, intensive care unit admission and invasive procedures at the end of life, according to an extensive new study published in the Journal of the American Medical Association. Hospice patients also incur significantly lower medical costs than non-hospice patients.

Researchers, led by Dr. Ziad Obermeyer, an emergency medicine physician at Brigham & Women’s Hospital, studied hospice and non-hospice patients using a nationally representative sampling of Medicare fee-for-service beneficiaries who died in 2011. Some 18,000 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 11 days.

The average costs of care for patients in their last year of life in the non-hospice group was $71,517, compared to $62,819 for those enrolled in hospice; savings totaled close to $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. Recent studies indicate the vast majority of Americans wish to die at home, but rarely do.

Dr. Ziad Obermeyer
Dr. Ziad Obermeyer, lead researcher

“While enrolled in hospice, beneficiaries were hospitalized less, received less intensive care, underwent fewer procedures and were less likely to die in hospitals and skilled nursing facilities,” researchers write. “Over similar periods before death, most non-hospice beneficiaries were admitted to hospitals and ICUs for acute conditions not directly related to their poor-prognosis cancer. Such care is unlikely to fit with the preferences of most patients.”

Hospice care is designed to help comfort the seriously ill near the end of life, and it has become increasingly popular in recent years – reaching nearly $14 billion in payments during 2011. The Medicare hospice benefit, established in 1982 to help patients pay for care, is usually provided only to those with a life expectancy of six months or less.

The findings also highlight the importance of frank, honest discussion between doctors and patients about goals of care. The Centers for Medicare and Medicaid Services is debating the risks and benefits of reimbursing physicians for end of life discussions, proposals removed from President Obama’s Affordable Care Act.

Dr. Joan Teno, associate director of the Center for Gerontology and Health Care Research at Brown University Medical School, says that the cost savings associated with hospice care are much less important than the health benefits it provides seriously ill patients.

“A key policy concern is if hospice saves money, should health care policy promote increased hospice access? Perhaps an even larger policy issue involves the role of costs and not quality in driving U.S. health policy in care of the seriously ill and those at the close of life,” she writes in an accompanying editorial. “The general expectation is that persons who choose to enroll in hospice should not die in an acute care hospital, and their hospital expenditures should be less than if they were not enrolled in hospice.”

A recent study led by Teno suggests some newer for-profit hospice programs have accepted patients too early and discharged others when the costs of caring for them rose. Nearly 20 percent of U.S. hospice patients are discharged before death, and not-for-profit and government-run hospices have lower rates of discharge than newer for-profit programs, according to the findings published in the Journal of Palliative Medicine.

“Dying patients are a vulnerable population and often are impoverished, frail, older, and cognitively impaired,” she adds. “As both private insurers and Medicare change the financial incentives in health care from doing ‘more’ to ‘less,’ there is an increased need for transparency and accountability.”