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Changes in Medicare costs with the growth of hospice care in nursing homes.

ABSTRACT: 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.).

SUBMITTER: Gozalo P

PROVIDER: S-EPMC4465278 | biostudies-literature | 2015 May

REPOSITORIES: biostudies-literature

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Changes in Medicare costs with the growth of hospice care in nursing homes.

Gozalo Pedro P Plotzke Michael M Mor Vincent V Miller Susan C SC Teno Joan M JM

The New England journal of medicine 20150501 19

<h4>Background</h4>Nursing home residents' use of hospice has substantially increased. Whether this increase in hospice use reduces end-of-life expenditures is unknown.<h4>Methods</h4>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 3 ...[more]

PMID: 25946281

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Project description:Background Hospice and palliative care nursing (HPCN) in China is mainly available at public primary care institutions, where nursing homes (NHs) are rarely involved. Nursing assistants (NAs) play an essential role in HPCN multidisciplinary teams, but little is known about their attitudes towards HPCN and related factors. Methods A cross-sectional study was designed to evaluate NAs’ attitudes towards HPCN with an indigenised scale in Shanghai. A total of 165 formal NAs were recruited from 3 urban and 2 suburban NHs between October 2021 and January 2022. The questionnaire was composed of four parts: demographic characteristics, attitudes (20 items with four sub-concepts), knowledge (nine items), and training needs (nine items). Descriptive statistics, independent samples t-test, one-way ANOVA, Pearson’s correlation, and multiple linear regression were performed to analyse NAs’ attitudes, influencing factors, and their correlations. Results A total of 156 questionnaires were valid. The mean score of attitudes was 72.44 ± 9.56 (range:55–99), with a mean item score of 3.6 ± 0.5 (range:1–5). The highest score rate was “perception of the benefits for the life quality promotion” (81.23%), and the lowest score rate was “perception of the threats from the worsening conditions of advanced patients” (59.92%). NAs’ attitudes towards HPCN were positively correlated with their knowledge score (r = 0.46, P < 0.01) and training needs (r = 0.33, P < 0.01). Marital status (β = 0.185), previous training experience (β = 0.201), location of NHs (β = 0.193), knowledge (β = 0.294), and training needs (β = 0.157) for HPCN constituted significant predictors of attitudes (P < 0.05), which explained 30.8% of the overall variance. Conclusion NAs’ attitudes towards HPCN were moderate, but their knowledge should be improved. Targeted training is highly recommended to improve the participation of positive and enabled NAs and to promote high-quality universal coverage of HPCN in NHs. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-023-01175-8.

Project description:ImportanceMore patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it.ObjectiveTo compare utilization and costs of health care for patients with poor-prognosis cancers enrolled in hospice vs similar patients without hospice care.Design, setting, and participantsMatched cohort study of patients in hospice and nonhospice care using a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies) enrolled in hospice before death were matched to similar patients who died without hospice care.ExposuresPeriod between hospice enrollment and death for hospice beneficiaries, and the equivalent period of nonhospice care before death for matched nonhospice patients.Main outcomes and measuresHealth care utilization including hospitalizations and procedures, place of death, cost trajectories before and after hospice start, and cumulative costs, all during the last year of life.ResultsAmong 86,851 patients with poor-prognosis cancers, median time from first poor-prognosis diagnosis to death was 13 months (interquartile range [IQR], 3-34), and 51,924 patients (60%) entered hospice before death. Matching yielded a cohort balanced on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization, with 18,165 patients in the hospice group and 18,165 in the nonhospice group. After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. After exposure, nonhospice beneficiaries had significantly more hospitalizations (65% [95% CI, 64%-66%], vs hospice with 42% [95% CI, 42%-43%]; risk ratio, 1.5 [95% CI, 1.5-1.6]), intensive care (36% [95% CI, 35%-37%], vs hospice with 15% [95% CI, 14%-15%]; risk ratio, 2.4 [95% CI, 2.3-2.5]), and invasive procedures (51% [95% CI, 50%-52%], vs hospice with 27% [95% CI, 26%-27%]; risk ratio, 1.9 [95% CI, 1.9-2.0]), largely for acute conditions not directly related to cancer; and 74% (95% CI, 74%-75%) of nonhospice beneficiaries died in hospitals and nursing facilities compared with 14% (95% CI, 14%-15%) of hospice beneficiaries. Costs for hospice and nonhospice beneficiaries were not significantly different at baseline, but diverged after hospice start. Total costs over the last year of life were $71,517 (95% CI, $70,543-72,490) for nonhospice and $62,819 (95% CI, $62,082-63,557) for hospice, a statistically significant difference of $8697 (95% CI, $7560-$9835).Conclusions and relevanceIn this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.

Project description:ImportancePatients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs.ObjectiveTo examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis.Design, setting, and participantsThis cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017.Main outcomes and measuresHospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life.ResultsAmong 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life ($10 756 vs $10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221).Conclusions and relevanceOverall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.

Project description:BackgroundHospitals are increasingly at risk for post-acute care outcomes and spending, such as those in skilled nursing facilities (SNFs). While hospitalists are thought to improve patient outcomes of acute care, whether these effects extend to the post-acute setting in SNFs is unknown.ObjectiveTo compare longer term outcomes of patients discharged to SNFs who were treated by hospitalists vs. non-hospitalists during their hospitalization.DesignThis was a retrospective cohort study.ParticipantsParticipants are Medicare fee-for-service beneficiaries over 66 years of age who were hospitalized and discharged to a SNF in 2012-2014 (N = 2,839,779).Main measuresWe estimated the effect of being treated by a hospitalist on 30-day rehospitalization and mortality, 60-day episode Medicare payments (Parts A and B), and successful discharge to community. Patients discharged to the community within 100 days of SNF admission who remained alive and not readmitted to a hospital or SNF for at least 30 days were considered successfully discharged. All outcomes were adjusted for demographics and clinical characteristics. To account for heterogeneity across facilities, we included hospital fixed effects.Key resultsThe 30-day rehospitalization rate was 17.59% for hospitalists' vs. 17.31% for non-hospitalists' patients (adjusted difference, 0.28%; 95% CI, 0.13 to 0.44). Sixty-day payments were $26,301 for hospitalists' vs. $25,996 for non-hospitalists' patients (adjusted difference, $305; 95% CI, $243 to $367). There was a non-significant trend toward lower successful discharge to the community rate (adjusted difference, - 0.26%; 95% CI, - 0.48 to - 0.04) and lower mortality for patients of hospitalists (adjusted difference, - 0.12%; 95% CI, - 0.22 to - 0.02).ConclusionsAmong hospitalized Medicare beneficiaries who were discharged to SNFs, readmissions and Medicare costs were slightly higher for stays under the care of hospitalists compared with those of non-hospitalist generalist physicians, but there was a non-significant trend toward lower mortality.

Project description:ImportanceMedicare adopted transitional care management (TCM) payment codes in 2013 to encourage clinicians to furnish TCM services after beneficiaries were discharged to the community from medical facilities. To bill for the 30-day service, a care team member must communicate with the beneficiary or the caregiver within 2 business days after the discharge and the clinician must provide an office visit within 14 days.ObjectiveTo investigate whether the receipt of TCM services was associated with the subsequent health care costs and mortality of the beneficiaries in the month after the service was provided.Design, setting, and participantsRetrospective cohort analysis of all Medicare fee-for-service claims for the period of January 1, 2013, through December 31, 2015, for 18 756 707 Medicare fee-for-service beneficiaries with discharges eligible for subsequent TCM services. Discharges from a hospital, an inpatient psychiatric facility, a long-term care hospital, a skilled nursing facility, an inpatient rehabilitation facility, or an outpatient facility for an observational stay were included. Data analysis was performed from July 2016 to March 2018.ExposureFurnishing of TCM services for the 30 days following an eligible discharge for Medicare beneficiaries as reflected in Medicare fee-for-service claims.Main outcomes and measuresTotal Medicare (Parts A, B, and D) health care costs and mortality in the 31 to 60 days after discharge, which is 30 days beyond the potential period for which the beneficiary could receive TCM services. Health care costs and mortality were adjusted for beneficiary age, sex, risk score, dual eligibility for Medicare and Medicaid, type of eligible discharge, year of discharge, and whether the eligible discharge to the community included home health care.ResultsOf 18 756 707 eligible Medicare beneficiaries during the study period, 43.9% were male and had a mean (SD) age of 72.5 (13.8) years. Transitional care management services were billed following eligible discharges in 3.1% of cases in 2013, 5.5% in 2014, and 7.0% in 2015. The adjusted total Medicare costs ($3358; 95% CI, $3324-$3392 vs $3033; 95% CI, $3001-$3065; P < .001) and mortality (1.6%; 95% CI, 1.6%-1.6% vs 1.0%; 95% CI, 1.0%-1.1%; P < .001) were higher among those beneficiaries who did not receive TCM services compared with those who did receive TCM services in the 31 to 60 days following an eligible discharge.Conclusions and relevanceDespite the apparent benefits of TCM services for Medicare beneficiaries, the use of this service remains low. An assessment should be made of interventions that can increase the appropriate use of this service.

Dataset Information

Changes in Medicare costs with the growth of hospice care in nursing homes.

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Changes in Medicare costs with the growth of hospice care in nursing homes.

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