Over one third of Medicare beneficiaries with heart failure received hospice care during the last six months of life. Hospice care was associated with substantial reductions in acute care utilization and related expenditures. After offsetting costs related to hospice care, the apparent net savings were about $3000 per decedent, among 16,000 heart failure decedents in 2007. However, these apparent savings appeared to be explained by confounding demographic factors related to both hospice care and end-of-life expenditures. After accounting for those confounders, total expenditures among decedents who used hospice care were 4% higher than their counterparts who did not receive hospice care. These results suggest that in heart failure patients, hospice care substitutes for acute care with a slight increase in total costs.
Only about one third of elders with heart failure received hospice care during the last six months of life, but previous studies suggest that hospice use is increasing in this patient population. 8, 19
However, the majority of hospice enrollees in our study received less than one month of hospice care and over a third received hospice care for seven days or less, implying that, despite increases in enrollment, hospice care in many heart failure patients is introduced quite late, within days of death. These findings are consistent with prior studies that indicate lower use of hospice care for heart failure than for cancer. 14, 20, 21
One possible explanation for low hospice use in heart failure is the variable clinical course of the disease, which makes prognostication difficult. 9
In our study, Medicare beneficiaries with heart failure who were enrolled in hospice care had lower rates of high intensity care including hospitalization, intensive care unit days, cardiac catheterizations, ICD placement, dialysis, and mechanical ventilation during the last six months of life. These results are consistent with findings of decreased utilization of intensive medical services related to hospice care among Medicare beneficiaries with cancer. 22
Decreased rates of hospitalizations and ICU admissions are considered to be an indicator of good quality of end of life care and are generally associated with increased patient satisfaction. 23, 24
We were unable to assess satisfaction or quality of life in our study, which was limited by the nature claims data.
Since the introduction of the hospice benefit in Medicare, there has been significant debate whether hospice care can reduce costs. 25
A number of studies have found hospice use to be associated with lower costs 13, 26, 27
although results have not been consistent. 26, 28
One study of Medicare beneficiaries during the last year of life during the period of 1996 to 1999 found hospice care to be associated with 4% increase in expenditures. 12
Our study expands upon this work by showing a similar increase in expenditures among a contemporary cohort of individuals specifically with heart failure. Furthermore, we demonstrated these increased expenditures despite reduced hospitalizations and procedures, implying a cost tradeoff of acute care services for hospice related care.
Our finding of an association between hospice care and increased expenditures was primarily driven by beneficiaries with low total expenditures; in fact, among beneficiaries in the highest quintile of total expenditures, beneficiaries with hospice care had lower mean expenditures as compared to those who had not enrolled in hospice. These results were partly due to the distribution of total expenditures for beneficiaries with hospice care, the majority of who were in the middle quintiles of total expenditures. Furthermore, expenditures for hospice beneficiaries were higher at the 25th percentile but lower at the 75th percentile as compared to beneficiaries with no hospice care. This less skewed, with a higher median, distribution of expenditures in the hospice group as compared to the non-hospice group may reflect that hospice is associated with constant expenses as compared to less regular and potentially high costs of medical treatment near the end of life. Among beneficiaries who are relatively low utilizers of care, the daily expenses for hospice, which include care management, home services, and medications, appear to exceed any savings due to reduced hospitalizations, procedures, and other medical services. Conversely, among beneficiaries who are high utilizers, the cost of hospice care appears to be more than offset by the associated reduction in acute medical care. The challenge for payers and providers is to identify individuals who are “at risk” of high utilization.
Demographic characteristics associated with reduced total expenditures in our study included increased age and Midwest or South regions. Previous studies have shown that both age 29–31
and region 29, 32
influence expenditures near the end of life in the general population, although this has been less well studied among a cohort of individuals with heart failure. Additionally, among a cohort of Medicare beneficiaries with heart failure, we found that age and region mediate the association between hospice care and expenditures near the end of life.
In our study, age, gender, and race were associated with enrollment in hospice care among individuals with a prior diagnosis of heart failure. Older age has previously been shown to be correlated with increased hospice referral in the heart failure population. 19, 33
Our findings on racial differences were consistent with previous literature which has demonstrated that African Americans are less likely to receive hospice care than their white counterparts for cancer 34–37
and for heart failure. 33
These racial disparities may be due to unmeasured clinical or demographic characteristics, although cultural beliefs, physician mistrust, 38, 39
and lack of information 39
are also likely contributors. A better understanding of causes of racial differences in hospice use in end stage heart failure is needed, with a particular focus on the role of access versus patient preferences on utilization of this service.
Our study has several limitations which deserve mention. First, our reliance on ICD-9 diagnosis coding could have led to errors in misclassification, but we used a well-validated approach to identify heart failure. 40
Second, while we included individuals with a diagnosis of heart failure, we could not determine whether hospice care was directly related to heart failure. Nonetheless, we found similar results after excluding beneficiaries with cancer. Third, we lacked data on both direct and indirect costs to patients and their families, which would have underestimated the total expenditures in our sample. Fourth, our primary exposure was evaluated concurrently with our outcome meaning that utilization may have occurred either prior to hospice enrollment or after hospice disenrollment. However, in our sensitivity analysis, the results for total expenditures were similar for individuals who had spent at least thirty days or the full six months in hospice as for the overall cohort. Fifth, we were unable to determine the site of delivery of hospice care, although, within Medicare, over 95% of hospice days are provided as home care. 11
Sixth, like all ‘end-of-life’ studies based on a sample of decedents, we could not evaluate the influence of acute care, procedures, or hospice care on survival. 41
Although conventional wisdom is that acute care and procedures extend life, hospice care may also be associated with a reduction in mortality in heart failure. 42
Finally, our use of claims data did not allow for evaluation of patient preferences, quality of life, and other patient reported outcomes which are crucial in decision-making in end-of-life care.
In conclusion, despite lower rates of hospitalization, ICU days, and invasive procedures, hospice care was not associated with reduced expenditures for heart failure patients following adjustment for covariates. Within Medicare, financial savings related to reduced intensive medical care appear to be offset by the expenditures related to hospice care itself. As currently deployed, hospice care for heart failure patients does not appear to be cost-saving, but it may well have non-economic benefits that justify its additional cost. Whether more appropriate deployment of hospice care might enhance both economic and non-economic benefits for individuals with heart failure deserves further attention.