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.

Palliative care as a win-win

Palliative care offers multiple benefits. Pain can slow the healing process. It extends hospital stays, prolongs needless suffering and erodes a patient’s capacity to adhere to prescribed treatment.

A 2008 Journal of Palliative Medicine study measured the impact of palliative care on patient satisfaction, clinical outcomes and cost of care for six months after being released from the hospital. Patient satisfaction was higher, more advance directives were completed, fewer ICU admissions were necessary and overall medical costs were lower compared to patients with life-limiting illnesses not in palliative care. Patient satisfaction stems primarily from palliative care’s patient-centered approach, which incorporates personal values and preferences.

This is in contrast to the usual intensive care many patients receive regardless of their preferences. More than half of Medicare spending on beneficiaries in their last two years is for hospital costs. About 25 percent of total Medicare costs is spent for patients in the last year of life. Most of those expenses are for hospitalizations, including readmissions and ICU stays. One out of 5 cancer patients are still receiving chemotherapy in the last two weeks of life.

Patient satisfaction with hospital care is inversely related to intensity of care. It falls in direct proportion to higher spending, greater use of resources and intrusive care.

Early palliative care can actually extend life. A 2010 study found that people with lung cancer who received the care lived three months longer, compared with those receiving standard care. Those with lung cancer can expect to get only two or three additional months of life at most from chemotherapy.

Despite its advantages, there are several barriers to widespread use of palliative care. Physicians are trained to save lives, even if it requires aggressive measures. It is often not clear at what point a condition becomes inevitably terminal. For many physicians and their patients, palliative care represents a surrender of sorts. Aggressiveness is the default approach to end-of-life care in the U.S.

An intensive battery of procedures and tests is paid for by Medicare and private insurers without questions. Reimbursement for palliative care is less certain. Medicare and private insurers pay for some palliative care, but the billing can be less comprehensive and more complicated than for standard hospital care, and physicians may consider this too burdensome. Customarily, most health plans do not pay for time-consuming care coordination and shared decision-making.

To counter these barriers, in 2010 Gov. David A. Paterson signed into law the New York Palliative Care Information Act, which requires physicians to offer terminal patients and their families information about prognosis and options for end-of-life care. New York State’s medical society opposed the law because they believed the government was intruding on the physician-patient relationship.

Palliative care is not necessarily intended to be less expensive care, but that often is the result. A hospitalized palliative-care patient costs $279 to $374 less a day. There are significant reductions in pharmacy, laboratory and ICU costs. The average annual savings of a palliative-care program is $1.3 million for a 300-bed community hospital and $2.5 million for an average academic medical center.

In a study of Medicaid patients in four hospitals in New York state, patients who received palliative care cost $6,900 less during a hospital stay compared with those who received standard care.

In Spain, a 2006 study found that a shift to palliative and at-home care and away from traditional hospitalization saved 61 percent.