Hospices Struggle to Balance Costs, Patient Needs in Medication Deprescribing

When deprescribing medications for hospice patients, providers have to navigate a complex web of factors. But according to some clinicians, the prospect of cost savings often takes precedence over clinical outcomes.

Medication costs are among hospices’ biggest expenses, and deprescribing some medications deemed “curative” or “unrelated” to the patient’s terminal diagnosis is a standard practice. However, even in the context of providing comfort care at the end of life, many patients do not receive medications that could benefit them, including those for pain management.

“We have a patient on a heart medicine that we’ll bring to hospice, but they have to come off of that heart medicine in two weeks. Because if I leave you on that heart medicine, that cost anywhere from $1,000 a month up to $20,000 a month, depending on which brand of medication it is,” a hospice nurse speaking on condition of anonymity told Hospice News. “Everything is based on cost. A medicine that will keep that patient alive for probably six months is too expensive for the hospice to pay for. So we have to give them a deadline.”

The nurse provided an example from her own patients: A female patient dying of cancer is being cared for by her 22-year-old daughter. The patient is receiving oral morphine, which costs approximately $13 a bottle and likely less than $100 per month, the nurse indicated.

But, due to the use of an oral solution, the caregiving daughter has to administer the medication every hour on the hour, which disrupts her sleep and adversely affects her own health.

“If the hospice would allow a morphine or dilaudid drip, that’s going to cost them $350 to $600 a month,” the nurse said. “The daughter could sit and hold her mother’s hand, as this medicine slowly kept her out of pain on a constant basis, and the daughter could sleep.”

Hospices under pressure

Given today’s reimbursement pressures, coupled with inflation and rising labor costs, expenses are a very real concern for hospice providers, particularly smaller organizations with tight margins.

The U.S. Centers for Medicare & Medicaid Services (CMS) gave hospices a 3.1% increase to their per diem payments for 2024, but providers say that the proposed increase is simply not enough to offset the financial obstacles they must overcome to sustain their services.

In public comments on the proposed 2024 payment rule, the National Hospice and Palliative Care Organization (NHPCO) estimated that a total 6.5% increase would be necessary to keep pace with providers’ climbing costs.

The major industry groups were in consensus that the increase was insufficient.

“While we appreciate the payment increase to 3.1%, a more generous market basket update was badly needed for nonprofit, mission-driven hospice providers committed to continuing to provide quality care in their communities,” Katie Smith Sloan, LeadingAge president and CEO, said in a statement shared with Hospice News. “Even with this increase, conditions on the ground require more support: workforce costs are higher than ever; nurses and aides are scarce, and cost for supplies, drugs, gas, and other expenses are all inflated.”

A complex clinical question

Even without the cost concerns, deprescribing is a complicated process from a purely clinical standpoint as well. Clinical practice guidelines are more clear regarding the initiation of medications, but often unclear about when discontinuation is safe and appropriate, a 2019 study in the journal Clinical Medicine indicated.

Providers also must balance the potential risks associated with deprescribing against other concerns that could arise from continuing a medication. Due to polypharmacy, hospice patients are often at great risk for adverse side effects, such as falls, confusion and medication interactions, among others, according to a 2022 dissertation by Shannon Dickson at the University of Massachusetts-Amherst.

Reinvesting cost savings

CMS has a role to play in addressing this issue, according to Dr. Monisha Pujari, medical director for Longleaf Hospice. For one, the agency should re-invest some of the cost savings that hospices generate into stronger reimbursement for those services, she said.

“We need to shift into a system that understands how to pay for a lot more at the end of life than we’re doing now. Ironically, that is even cheaper than the hospital,” Pujari told Hospice News. “Hospital stays are very expensive, on the order of tens of hundred of thousands of dollars. I could use some of those dollars to run multiple modalities in the home, if we had a payer system that understood that that was where we would get the most benefit.”

Last year, a report from NORC at the University of Chicago, NHPCO and the National Association for Home Care & Hospice (NAHC) quantified the amount of dollars that hospices save Medicare.

The joint report published in March found that hospice care — regardless of length of stay — saves Medicare approximately $3.5 billion for patients in their last year of life, a 3.1% reduction. But those with stays of six months or more yielded the highest percentage of savings at 11%.

“Where we would get the most benefit is shifting the model outside of the hospital, back into hospice, back into the home and starting to think about how we pay for these things in the home,” Pujari said. “We are asking patients to stop medication and treatments arbitrarily, just to save dollars. Many people don’t get what they need. There are a lot of patients out there who are not getting high-level management.”