There was substantial growth in the number of hospices providing care in NHs and this growth was significantly associated with increased rates of hospice use. Furthermore, increased rates of hospice use were accompanied by dramatic increases in mean hospice stays. Herein lays the concern. While increased access to hospice care in NHs had been promoted,30
increased access appears to come at a cost of longer stays and these have resulted in increased Medicare hospice expenditures.19
Furthermore, although increases in hospice use are a likely response to unmet needs,24, 25
greater growth in long stays were observed in the ten states with the most versus the least provider growth even though both groups had similar increases in noncancer patients. Further study is needed to understand the provider and/or healthcare market factors influencing these differences.
In the US, 67% of older persons with dementia-related diagnoses and 28% of persons with other noncancer diagnoses die in NHs, while only 21% of those with cancer diagnoses die in NHs.1
Therefore, to provide hospice care to all but a very small proportion of dying NH residents means substantial care will be provided to persons with noncancer diagnoses, a high proportion of who will have dementia-related diagnoses. We observed this firsthand since the proportion of hospice NH decedents with noncancer diagnoses was sizable (at 69%) even prior to the substantial growth of hospice providers, when only 14% of decedents accessed hospice. However, while 83% of NH decedents had noncancer diagnoses in 2006, only 31% percent accessed hospice. In contrast, 51% of NH decedents with cancer diagnoses accessed hospice in 2006. This large discrepancy in access reflects the continuing barriers to Medicare hospice for persons with (noncancer) chronic terminal illnesses in NH and non-NH settings.24-26
Mean hospice stays for NH decedents more than doubled, from 46 days in 1999 to 93 days in 2006. Additionally, in 2006 the 93 day mean hospice stay for NH decedents is estimated to be at least 20 days longer than the mean stay for non-NH hospice decedents (based on the proportion of all Medicare hospice provided in NHs, the mean NH stay and on MedPAC length of stay data for all hospice decedents).19
This longer mean stay for NH decedents is consistent with NH case-mix differences (as discussed above) and with the more bimodal distribution of hospice lengths of stay for persons with noncancer diagnosis.31
Still, as discussed above, it appears differing provider and/or healthcare market behavior may influence the presence of longer long stays (days of stay at 90th
percentile) since increases in these days were significantly greater in the ten states with the greatest versus least provider growth.
Our study provides new information showing almost a third of Medicare beneficiaries dying in NHs accessed Medicare hospice in 2006, and given the observed trends this growth in use is likely continuing. Additionally, other recent research has shown 40% of NH decedents with end-stage dementia and 35% of those with a co-morbid dementia diagnoses accessed hospice in 2006.32
Therefore, calls for elimination of Medicare hospice in NHs based on its underuse appear unfounded,21, 22
especially considering our finding that use in the NH mirrored the overall growth in Medicare hospice use. Additionally, the notion that the complexity of NH-hospice collaborations is a major obstacle to the viability of hospice care in NHs22
also appears unfounded given the high proportion of U.S. NHs contracting with hospice providers and the documented outcomes resulting from this collaborative care.4, 9, 12-16
Nevertheless, the argument that the design of the Medicare hospice benefit creates barriers to its access21, 22
There are major shortcomings in the Medicare hospice benefit that appear to influence the timing of referral (resulting in very short and long stays),33
and that may limit further increases in access for NH residents. First, the need for a physician-certified six-month terminal prognosis creates substantial barriers for persons with (noncancer) chronic terminal illnesses for whom a six-month prognosis is difficult.24, 25
While this barrier affects persons dying in NHs and in other settings (and 72% of persons with non-dementia chronic terminal illnesses die in non-NH settings),1
the barrier is particularly important in NHs given the high proportion of NH residents with chronic terminal illnesses. Another major barrier arising from the Medicare hospice benefit is the requirement that beneficiaries enrolling in hospice must forgo other Medicare-Part A care (when such care is related to the terminal illness). For beneficiaries in the community or in NHs this means hospital care and curative treatment must be abandoned, but it often also means abandonment of expensive treatments such as blood transfusions or palliative radiation (when hospices lack financial resources to support such care).24-26
Additionally, in NHs the Medicare Part A forfeiture requirement creates a system-wide barrier since dying NH residents routinely receive Medicare Part-A skilled nursing facility (SNF) care (after hospitalizations),34
and its forfeiture is financially disadvantageous for NHs and families.35
Even given these barriers, we did find a third of NH decedents in 2006 enrolled in Medicare hospice. However, as expected, a high proportion of hospice stays were seven days or less (30.6% in 2006) or over 181 days (15.6% in 2006; Table 2).
While most U.S. NHs approach the provision of end-of-life palliative care by referring residents to hospice, many NHs also invest in developing internal palliative care programs/expertise (with or without hospice care).11
The few studies that have tested the integration of (nonhospice) palliative care expertise and processes into NHs have shown improvement in care processes,36-40
and when combined with a quality improvement program, a reduction in pain prevalence.41
However, there has been no widespread dissemination of any of these efforts. In 2004, 27 % of U.S. nursing homes reported having special programs and (specially) trained staff for hospice or palliative/end-of-life care but information on the scope of practices included in these programs was not reported.11
More study is needed to understand the extent and breadth of nonhospice palliative care provision and expertise in U.S. NHs, the resulting quality outcomes, and the feasibility of its widespread implementation. Without a more in-depth understanding of what NH practices and investments result in higher quality palliative care outcomes and whether the few small-scale studies can be replicated across a broad range of NHs, paying NHs more to provide “palliative care” in lieu of paying Medicare-certified hospices21
is ill-advised. At present, given our current understanding of NH end-of-life care and of the benefits and use of hospice care in NHs, 5-8, 14, 16
the provision of NH-hospice collaborative care appears to be the most feasible option for widespread improvement of dying residents' quality of care and life.10
Notwithstanding this, increased palliative care knowledge and (availability to) expertise in NHs and in other healthcare settings continues to be needed to ensure high-quality symptom management to persons who do not qualify for or choose hospice, and payment or quality indicator oversight efforts to incentivize such symptom management are desirable.
The MedPAC has recommended changing the Medicare payment system so the per diem rate for hospice routine home care (95% of all hospice care days) better reflects the intensity of hospice service provision.19
Since research has shown hospice visits to be more frequent at time periods closer to the beginning and end of hospice episodes,42-44
it is reasonable to have higher payment rates around the time of hospice admission and around the time a patient is dying. The MedPAC has also recommended closer scrutiny of recertification of hospice patients after the 180th
day of stay, specifically, they propose requiring patient visits by physicians or advanced practice nurses to evaluate their continued eligibility and need for care.19
Together, these recommended approaches to curbing Medicare costs appear to be a viable option for both retaining access while reducing the number of long (costly) hospice stays (some of which appear to result from perverse financial incentives). However, evaluation of such a payment option must include consideration of variations in hospice use in NHs (as shown here) and the probable greater impact of changes on hospice access for dying NH residents, given the high proportion of persons with noncancer diagnoses in NHs.
In conclusion, given the increasingly high proportion of Medicare beneficiaries who die in NHs and their entitlement to and benefit from the Medicare hospice benefit, denying them access to NH hospice is not desirable. Our analyses provide new information on the increased use of hospice care in NHs and show substantial increases in very long hospice stays. As such, our data support the need for a modification in the current Medicare hospice reimbursement systems which would vary payments as a function of length of stay.19
However, it is important for any new policy to explicitly acknowledge the challenges inherent in the timing of hospice referral for NH residents in the last stages of (noncancer) chronic terminal illnesses24-26
by recognizing “early” referrals will occur and deeming them “acceptable” in the presence of well-documented physician evaluations and eligibility determinations. Without such explicit acknowledgement the fear is that undue scrutiny may occur, resulting in decreasing enrollments and a higher prevalence of very short stays.