Skip to main content

The Medicare Hospice Benefit: A Challenge to the Concerns About the Rise in Cost

I was very disappointed with the recent New York Times Article “Concerns About Costs Rise With Hospices’ Use.” The article paints an unbalanced picture of the Medicare Hospice Benefit highlighting “the concerns about excessive costs and misuse” while omitting many of the safeguards in place that are effectively working to prevent fraud. The Medicare hospice benefit is currently a misunderstood and underutilized benefit and unfortunately articles such as this can only perpetuate this problem.

The author states “once a patient is enrolled in hospice, Medicare pays a flat fee ranging from $147 to $856 a day, depending on the level of care, regardless of whether a hospice actually provides services” implying that Medicare will pay for all hospice patients for an unlimited amount of time regardless of whether they receive care. The article failed to mention that hospice agencies currently are subject to an aggregate financial cap. The Medicare cap amount is approximately $24,000 per hospice beneficially per year. The aggregate cap is calculated as the product of the individual beneficiary cap amount and the "number of Medicare beneficiaries" in a hospice program in any given accounting year. Agencies where the majority of patients live longer than 6 months will exceed the cap amount and will be required to repay Medicare - essentially providing free service to their patients. The aggregate cap ensures that the average length of stay of all hospice patients is less than 6 months. Each hospice agency is also required a minimum of one house call nursing visit to each patient every two weeks and to report the services that they provide to Medicare – it is doubtful that many agencies will be paid if they are not providing any services.

Of note, the assertion that “When properly used — that is, at the very end of life — hospice care also has saved the government money” is being challenged. Data suggests that hospice care is cost effective when used earlier. For this reason legislation is currently being considered to establish a 3-year moratorium on Medicare's calculation and collection of the hospice cap, and to authorize a study on the resource-effectiveness and quality of the hospice benefit compared to other Medicare acute care alternatives.

The article highlights companies that were found to be fraudulent by Medicare whistleblowers and required to repay Medicare millions of dollars for “discouraging hospice discharges” and trying to find a way to “keep patients on as long as possible” strongly implying that fraudulent long length of stays are a widespread hospice problem. Yet the article also mentions that the “median time spent in hospice care now is just 17 days.” If the majority of hospices were fraudulently keeping patients on wouldn’t the overall length of stays be longer? Or could it mean that this isn’t really an overwhelming problem? Interestingly, the article states that “in 2009, 10 percent of patients remained in hospice beyond seven months” which also means that 90% of patients remained in hospice less than seven months.

“Medicare’s bill for hospice care rose to more than $12 billion in 2009 from $2.9 billion in 2000.” This can seem startling when considered in isolation. To put this number in perspective approximately one-third of the total Medicare budget is expended on individuals at the end of life, but the Medicare hospice benefit represents a relatively small proportion of total Medicare spending. In 2010, an estimated 2.8 percent of Medicare benefit payments were spent on hospice care, with the same percent anticipated for 2011.

Although the bill for hospice care is rising, it will still be cost effective if the overall amount spent on end-of-life care decreases or if more patients can receive end-of-life care through hospice (instead of the 30% of the total Medicare budget currently spent in other venues such as the hospital or the ICU). As the author states “Providing dying patients with palliative care in their own homes, or in a hospice facility or nursing home, is far less expensive than continuing to order up futile medical treatments, studies have shown.” I think this last statement would have been a far better focus for the entire article.

by: Shaida Talebreza Brandon


Anonymous said…
How the NYT could write that article and just ignore the Medicare Cap is beyond me. They acted like it did not exist and hospices could just keep recertifying patients forever and receive payments. It is hardly a secret, Medicare Cap is tracked by every hospice provider in the country and has literally bankrupted some sizable providers. So irresponsible to play on ignorance like that.
Anonymous said…
We are all passionate about this matter, but may I offer a reality check so that we remain rational in addition to being passionate:
@ Anonymous #2: The conclusion of Goldfeld et al. supports the use of high-quality palliative care that seeks to reduce burdensome interventions for patients with advanced dementia.

Thanks Shaida for a really great piece.

It seems to me like the palliative care community is too often reacting to confusing or misleading media messages.

I think some consideration needs to be given to reaching out to the media with an array of fully developed narratives that anticipate areas of misunderstanding and proactively seek to clarify misunderstanding.

Not to sound too much like I have donned a tin-foil hat, but I suspect that a multiplicity developed narratives that increase confusion among the public are provided to the media by think tanks and other sources representing quarters whose economic and/or political agendas benefit from such doubt and confusion among the public. I believe that to not appreciate the sophistication and resources of some groups is naive, and leads to decreased message effectiveness as well as decreased benefit to patients, families and the public.
nursing home said…
Medical adult day care center is suitable for elders who have major health problems.
Dan Matlock said…
I think there is variability in the hospice care provided.

The OIG recently released a report documenting the unscrupulous behavior of some of the for profit hospices:

This is the Office of the Inspector General! - charged with looking for fraud!

Once again, the sins of for--profit medicine makes everyone look bad.
The article author should have been objective. He should know all the facts before writing about Medicare Hospice Benefit so he would not mislead the readers.
This is indeed misleading. Not all hospice care facilities operate just to earn money and disregard their patients suffering.

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…

Opening the Black Box of LTACs: Podcast with Anil Makam

What happens in Long Term Acute Care Hospitals, or LTACs (pronounced L-tacs)?  I've never been in one.  I've sent patients to them - usually patients with long ICU stays, chronically critically ill, with a gastric feeding tube and a trach for ventilator support.  For those patients, the goals (usually as articulated by the family) are based on a hope for recovery of function and a return home.

And yet we learn some surprising things from Anil Makam, Assistant Professor of Medicine at UCSF.  In his JAGS study of about 14,000 patients admitted to LTACHs, the average patient spent two thirds of his or her remaining life in an institutional settings (including hospitals, LTACs and skilled nursing facilities).  One third died in an LTAC, never returning home.

So you would think with this population of older people with serious illness and a shorter prognosis than many cancers, we would have robust geriatrics and palliative care in LTACs?  Right? Wrong.

3% were seen by a geriatrici…