Focus on Hospice length of use
March 24, 2014 1 Comment
I will be participating in a panel on Tuesday, March 25, 2014, 9:00-11:30am “The Right Care at the Right Time: An Open Conversation about Hospice Length of Stay” hosted by the Hospice Action Network, the advocacy arm of the National Hospice and Palliative Care Organization (NHPCO). The event will be held at the Columbus Club at Union Station in Washington D.C., but you can also watch via livestream.
Discussion on length of stay in hospice has largely been focused on worries about long periods of use (particularly those over 180 days)–that they may represent fraudulent or inappropriate care. Fraud is obviously a bad thing, but at least some of the long stays may essentially be the hospice benefit morphing into a back door long term care benefit of sorts. This is clearly not what is intended by the benefit, but such needs for patients and families are important, and the lack of a coherent long term care financing system in the U.S. is spilling over into Medicare policy in many places (hospice, readmissions, etc.).
Short stays in hospice represent potential quality problems, and the 25th percentile length of use has been ~5 days for a decade. Spells of use this short prior to death do not allow patients to reap the full benefits from hospice, but the call to increase length of use certainly has a normative tone; the persistence of such short lengths of use may also simply show the preferences of a subset of patients and families.
At the meeting I will present some preliminary work confirming that hospice saves Medicare ~$2,400 per patient after the point of initiation (in North Carolina, for 2009-10 deaths), as compared to matched controls for the same number of days of care/cost prior to death (this link is to many posts on hospice). These findings include the long stays, just as did my past work. Of course if you could get rid of long/inappropriate utilization, you would expand the cost saving potential of hospice. However, the behavioral response of any new change is unknown, and difficult to estimate a priori. The potential for unintended consequences abound, but there is a strong sense (that I share) that the hospice benefit in the Medicare program is in need of updating. Perhaps the most important question is this: What is(are) the goal(s) of hospice payment policy change(s)?