How 4 Questions Can Reduce Costs, Boost Hospice Utilization

A pilot program by an Accountable Care Organization (ACO) reduced per capita health care expenditures at a rural hospital by 70% and admissions by 98%. A key component of the initiative was a “Four Questions” framework for goals-of-care conversations.

The Center for Medicare & Medicaid Innovation ran the project between 2011 and 2015 at 32 participating hospitals and health systems.

During that period, one participating hospital, the nation’s third largest nondenominational health system at the time, achieved substantial cost savings while improving the patient experience, according to Dr. Tim Ihrig, CEO of Ihrig M.D. and Associates.


“You can help people live, love and laugh and learn and grow, even in the context of horrible progressive, irreversible terminal diseases, because they’re still alive,” Ihrig said at the Hospice News ELEVATE conference in Chicago. “Every hospice provider should be fluent, whether it’s those four questions or their own vernacular. At that level, you move it upstream, and that’s when you start to see a lot of significant change.”

The four questions used in the ACO demonstration were:

  • How are you?
  • Are you afraid?
  • What is sacred to you?
  • What does your “little voice” tell you [about life expectancy]?

The first question should be asked twice, according to Ihrig, because most people by reflex will say that they are “fine” or “good.”


The health system’s model included an inpatient program that captured nearly 40% of all patients that came to the hospital in a town of 40,000 people, Ihrig said. It also included a full-time ambulatory clinic as well as long term care facilities in several northern Iowa counties. Clinicians also did home visits with nurses on call 24/7.

The program also contributed to increases in patient and caregiver satisfaction rates, which reached 98%. These results can be replicated within other value-based models, such as the Value-Based Insurance Design Model (VBID).

“It’s on all our minds, the Medicare Advantage carve-in and how we are going to weather whatever changes come,” Irhig told Hospice News. “If we educate on how to ask questions and listen and act on that, we deliver value to our business partners. But most importantly we live in love and learn and grow through our last breath by approaching care differently.”

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