Hospice Care Patients Have Fewer Hospitalizations, Lower Costs at End of Life

Cancer patients who received hospice care during the last year of life had significantly fewer hospitalizations and lower overall costs than patients outside of hospice, according to a recent study of Medicare beneficiaries.

In a matched cohort study of over 18,000 pairs of Medicare patients with poor-prognosis cancers, researchers reported that non-hospice patients had significantly more hospitalizations, (65% vs 42%), intensive care (ICU; 36% vs 15%), and invasive procedures (51% vs 27%) than non-hospice patients. Total costs over the last year of life were $71,517 vs $62,819, a relative savings of nearly $9,000 per patient in hospice. The results are published in JAMA.

Hospital and ICU admissions of non-hospice patients were mostly related to acute conditions not related to their cancer, the study reported. Those patients were also more likely to die in hospitals or skilled nursing facilities compared with their hospice counterparts (74% vs 14%).

The results contradict concerns that increasing hospice use could lead to higher health care utilization and costs, the authors noted. Those concerns have fueled Medicare policies that sometimes discourage physicians from discussing end-of-life preferences and making early hospice referrals.

For example, Medicare monitors and prosecutes hospices for inappropriately long stays and does not reimburse physicians for end-of-life discussions. The agency also requires patients to formally renounce curative care before enrolling in hospice, which discourages patients who wish to continue active treatment regardless of prognosis.

“A key input to these debates is a better understanding of the relationship between hospice and health care utilization, and its implications for costs,” the authors wrote. “Our findings highlight the potential importance of frank discussions between physicians and patients about the realities of care at the end of life, an issue of particular importance as the Medicare administration weighs decisions around reimbursing physicians for advance care planning.”

In the study, hospice enrollments of 5 to 8 weeks produced the greatest costs savings while shorter stays produced fewer savings, likely due to the costs of initiating hospice care and providing symptom relief in the days before death.

“Overall these results may indicate that efforts to promote broader and earlier hospice uptake are unlikely to produce increases in total costs,” the authors said.

The authors acknowledged that the study has some limitations. For example, it does not take into account patient preferences for aggressive treatment, which could impact cost savings. It also limits the study population to patients with cancer.

The findings highlight an important policy issue regarding the role of cost vs quality in caring for the seriously ill and dying, said an accompanying editorial. Quality measures should be developed that incent health care professionals to focus on patients’ preferences at the end of life and not be overly influenced by the costs of care.

“That hospice or hospital-based palliative care teams save money is only ethically defensible if there is improvement in the quality of care and medical decisions are consistent with the informed patient’s wishes and goals of care,” said the editorial. “Choosing the ‘just right’ timing and setting for hospice care is a complex decision that should include consideration of several factors, including, most importantly, the preferences and goals of care of patients and their family.”