Providers to Lawmakers: Hospice a ‘Huge Value to Medicare’

Rising regulatory scrutiny around length of stay may be having adverse impacts on health care costs and quality, hospice leaders said in a recent Congressional briefing.

Fear of regulatory attention, audits or post-payment reviews related to longer stays could drive some hospice providers to discharge patients who can still benefit from their services, according to Dr. Joseph Shega, executive vice president and chief medical officer for VITAS Healthcare, a subsidiary of Chemed Corp. (NYSE: CHEM).

“In such a hyper-focus on length of stay, we’re going to start to see these adverse outcomes where we’re inadvertently causing harm by making these patients go to the emergency room and receiving care that’s unhelpful,” Shega said in the Capitol Hill briefing. “Whereas, if they could just stay on the benefit where they are truly still eligible, we would have that win-win situation of decreased total cost of care and improved outcomes. We know their prognosis is uncertain and we do our best, but patients are still declining.”

Longer stays yield greater savings

Regulators have fixed their gaze on longer hospice stays as signals of potential fraud, waste and abuse. However, longer stays, when clinically necessary, can generate cost-savings and improves quality, according to recent data.

Hospice care saves Medicare roughly $3.5 billion for patients in their last year of life, according to a joint report from the National Hospice and Palliative Care Organization (NHPCO), the National Association for Home Care & Hospice (NAHC) and NORC at the University of Chicago.

Longer stays yielded the highest amount of savings, as much as 11%, the research found.

Representatives from NHPCO, NAHC, NORC, along with hospice providers VITAS Healthcare and Delaware Hospice, presented the data during the briefing. 

“The value of this hospice study is one of the most statistically grounded, comparative assessments of hospice spending to date,” Dianne Munevar, vice president of health care strategy at NORC at the University of Chicago, said in the briefing. “The longer the hospice stay, the more potential savings.”

The new research comes at a time when regulators are raising more questions about the duration of hospice care and what it means for eligibility.

The U.S. Centers for Medicare & Medicaid Services (CMS) has been zeroing in on long lengths of stay as a potential indicator that suggests a hospice admitted someone who was not truly eligible. Additionally, the U.S. Department of Health & Human Services Office of the Inspector General (OIG) has planned a national audit on hospice eligibility this year, which will include examination of patients’ length of stay.

But earlier access to hospice, and longer duration of care, reduces high-cost, high-acuity utilization and results in better pain and symptom management, the NORC data indicated.

Stays longer than six months yielded the largest percentage of cost-savings, the data revealed.

Additionally, the research found that, nearly 90% of the time, the total cost of care for hospice patients in the last year of life was less than half of the spend for other patients.

“For majority of hospice costs, spending is still 12% lower compared to non-hospice. That’s a huge difference and a huge value to Medicare,” Munevar said. “Greater utilization of hospice during those last six months of life is [also] associated with improved patient experience and clinical outcomes. From the perspective of patients, there was less physical and emotional distress and better quality at the end of life.”

For majority of hospice costs, spending is still 12% lower compared to non-hospice. That’s a huge difference and a huge value to Medicare.

— Dianne Munevar, vice president of health care strategy, NORC at the University of Chicago

Among other findings, hospice admissions in the last six months of life were associated with increases in patient and caregiver satisfaction, better pain control management and reduced hospitalizations, Munevar indicated. Family feedback included reports that patients received the “right amount” of pain medication and services that aligned with loved ones’ goals of care and end-of-life wishes, she added.

Additionally, the research found that quality of life for family members during the last year of a patient’s life was also higher in hospice than without. Caregivers of hospice patients had less risk of prolonged grief disorders or disenfranchised grief, as well as less instances of post-traumatic stress disorder than those who did not receive these services, Munevar said in the hearing.

The workforce equation

Greater access and longer utilization of hospice care can also have positive impacts on workforce retention, according to Shega.

Clinical turnover can be higher when hospice stays are short, he said.

Hospice staff often experience higher rates of physical and emotional burnout, fatigue and exhaustion when they are unable to provide the full length and scope of interdisciplinary end-of-life care, he indicated.

“What you see is a convergence of pieces that come together in short lengths of stay in hospice that is not good for patients and families to derive the benefit,” Shega stated. “It’s much harder on staff because they have to do so much death work for the patient and family to try to meet their goals of care and make sure they achieve them, which leads to more burnout. Focusing the workforce on the entire health system to allow for earlier hospice access will help mitigate some of the workforce challenges.” 

Focusing the workforce on the entire health system to allow for earlier hospice access will help mitigate some of the workforce challenges.

— Dr. Joseph Shega, executive vice president and chief medical officer, VITAS Healthcare

Longer durations of hospice care can be a factor in sustaining clinical workforce capacity, according to Susan Lloyd, president and CEO of Delaware Hospice. The nonprofit hospice serves Delaware and parts of Pennsylvania.

The ability to balance longer hospice stays and patients’ changing needs is key when determining how to best allocate clinical staffing resources amid workforce shortages, Lloyd stated. This makes longer stays a sticking point for clinical retention and balanced patient caseloads, she indicated.

“It’s a difficult question, but workforce has been an issue for hospices particularly. It’s not easy work,” Lloyd said during the Congressional briefing. “Trying to find the right people for these jobs is critically important to sustain capabilities. Retention has been the bigger issue. Most of us are really concentrated on keeping the people we have because it does become an issue of your true capacity and being able to care for people longer.”