Changes in Medicare Costs with the Growth of Hospice Care in Nursing Homes
The use of hospice in nursing homes has increased substantially. In this analysis of Medicare expenditures in the last year of life for nursing home patients, hospice expansion between 2004 and 2009 was associated with a mean increase in Medicare spending of $6,800 per patient. Medicare expenditures...
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| Published in: | The New England journal of medicine Vol. 372; no. 19; pp. 1823 - 1831 |
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| Main Authors: | , , , , |
| Format: | Journal Article |
| Language: | English |
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United States
Massachusetts Medical Society
07.05.2015
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| ISSN: | 0028-4793, 1533-4406 |
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| Abstract | The use of hospice in nursing homes has increased substantially. In this analysis of Medicare expenditures in the last year of life for nursing home patients, hospice expansion between 2004 and 2009 was associated with a mean increase in Medicare spending of $6,800 per patient.
Medicare expenditures for beneficiaries in their last year of life account for a quarter of the annual payments made by Medicare.
1
From its inception, hospice has been viewed as respecting patients’ goals of care with no resulting increase — or even with a resulting decrease — in health care expenditures.
2
–
4
Between 2000 and 2012, the percentage of Medicare decedents using hospice doubled (from 23% to 47%)
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and hospice expenditures quintupled (from $2.9 billion to about $15.1 billion),
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which raised budgetary concerns.
6
,
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This increase was particularly large among persons with noncancer diagnoses and those residing in nursing homes.
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The . . . |
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| AbstractList | The use of hospice in nursing homes has increased substantially. In this analysis of Medicare expenditures in the last year of life for nursing home patients, hospice expansion between 2004 and 2009 was associated with a mean increase in Medicare spending of $6,800 per patient.
Medicare expenditures for beneficiaries in their last year of life account for a quarter of the annual payments made by Medicare.
1
From its inception, hospice has been viewed as respecting patients’ goals of care with no resulting increase — or even with a resulting decrease — in health care expenditures.
2
–
4
Between 2000 and 2012, the percentage of Medicare decedents using hospice doubled (from 23% to 47%)
5
and hospice expenditures quintupled (from $2.9 billion to about $15.1 billion),
5
which raised budgetary concerns.
6
,
7
This increase was particularly large among persons with noncancer diagnoses and those residing in nursing homes.
8
The . . . BackgroundNursing home residents’ use of hospice has substantially increased. Whether this increase in hospice use reduces end-of-life expenditures is unknown.MethodsThe expansion of hospice between 2004 and 2009 created a natural experiment, allowing us to conduct a difference-in-differences matched analysis to examine changes in Medicare expenditures in the last year of life that were associated with this expansion. We also assessed intensive care unit (ICU) use in the last 30 days of life and, for patients with advanced dementia, feeding-tube use and hospital transfers within the last 90 days of life. We compared a subset of hospice users from 2009, whose use of hospice was attributed to hospice expansion, with a matched subset of non–hospice users from 2004, who were considered likely to have used hospice had they died in 2009.ResultsOf 786,328 nursing home decedents, 27.6% in 2004 and 39.8% in 2009 elected to use hospice. The 2004 and 2009 matched hospice and nonhospice cohorts were similar (mean age, 85 years; 35% male; 25% with cancer). The increase in hospice use was associated with significant decreases in the rates of hospital transfers (2.4 percentage-point reduction), feeding-tube use (1.2 percentage-point reduction), and ICU use (7.1 percentage-point reduction). The mean length of stay in hospice increased from 72.1 days in 2004 to 92.6 days in 2009. Between 2004 and 2009, the expansion of hospice was associated with a mean net increase in Medicare expenditures of $6,761 (95% confidence interval, 6,335 to 7,186), reflecting greater additional spending on hospice care ($10,191) than reduced spending on hospital and other care ($3,430).ConclusionsThe growth in hospice care for nursing home residents was associated with less aggressive care near death but at an overall increase in Medicare expenditures. (Funded by the Centers for Medicare and Medicaid Services and the National Institute on Aging.) Nursing home residents' use of hospice has substantially increased. Whether this increase in hospice use reduces end-of-life expenditures is unknown. The expansion of hospice between 2004 and 2009 created a natural experiment, allowing us to conduct a difference-in-differences matched analysis to examine changes in Medicare expenditures in the last year of life that were associated with this expansion. We also assessed intensive care unit (ICU) use in the last 30 days of life and, for patients with advanced dementia, feeding-tube use and hospital transfers within the last 90 days of life. We compared a subset of hospice users from 2009, whose use of hospice was attributed to hospice expansion, with a matched subset of non-hospice users from 2004, who were considered likely to have used hospice had they died in 2009. Of 786,328 nursing home decedents, 27.6% in 2004 and 39.8% in 2009 elected to use hospice. The 2004 and 2009 matched hospice and nonhospice cohorts were similar (mean age, 85 years; 35% male; 25% with cancer). The increase in hospice use was associated with significant decreases in the rates of hospital transfers (2.4 percentage-point reduction), feeding-tube use (1.2 percentage-point reduction), and ICU use (7.1 percentage-point reduction). The mean length of stay in hospice increased from 72.1 days in 2004 to 92.6 days in 2009. Between 2004 and 2009, the expansion of hospice was associated with a mean net increase in Medicare expenditures of $6,761 (95% confidence interval, 6,335 to 7,186), reflecting greater additional spending on hospice care ($10,191) than reduced spending on hospital and other care ($3,430). The growth in hospice care for nursing home residents was associated with less aggressive care near death but at an overall increase in Medicare expenditures. (Funded by the Centers for Medicare and Medicaid Services and the National Institute on Aging.). |
| Author | Plotzke, Michael Miller, Susan C Mor, Vincent Gozalo, Pedro Teno, Joan M |
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| Snippet | The use of hospice in nursing homes has increased substantially. In this analysis of Medicare expenditures in the last year of life for nursing home patients,... Nursing home residents' use of hospice has substantially increased. Whether this increase in hospice use reduces end-of-life expenditures is unknown. The... BackgroundNursing home residents’ use of hospice has substantially increased. Whether this increase in hospice use reduces end-of-life expenditures is... BACKGROUNDNursing home residents' use of hospice has substantially increased. Whether this increase in hospice use reduces end-of-life expenditures is... |
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| SubjectTerms | Aged Aged, 80 and over Aging Cancer Dementia disorders Feeding Female Health Care Costs - trends Health care expenditures Health Expenditures - trends Hospice care Hospice Care - economics Hospice Care - trends Humans Least-Squares Analysis Male Medicare Medicare - economics Nursing homes Nursing Homes - economics Older people Propensity Score Terminal Care - economics United States |
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| Title | Changes in Medicare Costs with the Growth of Hospice Care in Nursing Homes |
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