Hospice: A runaway winner

The magazine Modern Healthcare held a “tournament” in 2011 to determine what “one person, event, organization or innovation had the biggest impact on the health-care delivery system in the past 35 years.” Hospice was “seeded” No. 12 at the beginning of voting. It was the landslide winner, beating out the Institute for Healthcare Improvement by a 3-to-1 margin.

Hospice care focuses on caring rather than curing. Most hospice care is provided in the patient’s residence. However, it is also available in hospice centers, some hospitals and long-term-care facilities.

Hospice caregivers use a variety of alternative therapeutic techniques to comfort patients. They use massage, group therapy, music therapy and pet therapy and guided imagery to supplement traditional pain-relief tactics.

Nearly 1.5 million patients were treated in hospice programs in 2008, compared with only 25,000 in 1982 when it first became a Medicare benefit. It is also covered by Medicaid and most private insurance plans. The average length of time in hospice is about 21 days. The National Hospice and Palliative Care Organization estimates that nearly 40 percent of 2008 U.S. deaths were in a hospice setting.

The three leading causes of death in hospice programs – cancer, Alzheimer’s disease and kidney disease – also are the easiest to predict remaining life expectancy, and they impose the greatest burdens on family caregivers.

Hospice care remains largely a white, upper-class and upper-middle-class phenomenon. Evidence indicates minority-group members generally are suspicious of the health-care system and are less open to the idea of withholding curative care. Many have had to forgo medical care most of their lives and have a different view of what it’s like to have nature take its course. A survey of more than 4,000 newly diagnosed cancer patients found that 80 percent of blacks said they were willing to exhaust their resources to extend life, compared with 64 percent of Hispanics and 54 percent of whites.

As with palliative care, hospice sometimes prolongs life. In a 2007 study, hospice patients survived nearly a month longer than non-hospice patients with comparable conditions did. Hospice care improved survival in 4 of 6 disease categories. The largest difference was for congestive heart failure, where average survival rose from 321 to 402 days.

Nonetheless, it is difficult for some patients to choose hospice because forgoing medical care seems like accepting a death sentence. However, research shows that patients who choose hospice care do not die faster than those who do not.

In a pilot test, Aetna allowed a group of policyholders with a life expectancy of less than a year to receive hospice care without abandoning medical care. The number of patients who chose hospice shot up to 70 percent from 26 percent. The cost of care for these patients was 25 percent less, despite the concurrent care. They visited the emergency room half as often as non-hospice patients with life-limiting conditions. Their hospital and ICU use dropped by two-thirds.

For Medicare patients, hospice care saves an average of $2,309 per patient. A 2007 study found that Medicare costs would be lower for 70 percent of hospice recipients if such care were provided earlier. Cost of care was less expensive for cancer up to 233 days and non-cancer cases up to 154 days. Thereafter, hospice costs more than conventional care. However, the authors said, “More effort should be put into increasing short stays as opposed to focusing on shortening long ones.”

For example, a study of men with advanced prostate cancer showed that about half eventually turned to hospice care but often waited until a week or two before death to enter the program. Brief hospice care delivers far fewer benefits.

More than two-thirds of hospice patients receive the services at home. However, a growing number of freestanding facilities are sprouting to meet demand. Construction of new hospice centers has increased by more than 40 percent since 2000. Nearly every U.S. citizen lives within 60 minutes of a hospice center, and 88 percent live within 30 minutes.

According to a 2010 study, the length of time that nursing-home patients are in hospice has doubled in the past decade, from 46 to 93 days. The study speculated that the increase was associated with a 50 percent growth in the number of nursing-home hospice programs. Medicare pays nursing homes far  more for hospice care than the facilities would receive for standard care from Medicaid. The Medicare Payment Advisory Commission has recommended that standards for hospice certification be strengthened to ensure nursing-home programs are qualified to provide care.