New trends in hospice care delivery are pointing to a growing need for improved equitable access and diversified services that address a broader range of disease-specific patient needs.

The scope of terminal conditions among hospice patient populations has seen some evolutions in recent years, according to Alix Ware, director of health policy at the National Alliance for Care at Home (the Alliance). Hospice providers have been expanding the depth of their interdisciplinary disease-specific programs to meet that need, Ware said.

Cancer has historically been the leading prognosis among hospice patients, but other illnesses have been increasing in prevalence. Alzheimer’s and dementia conditions, as well as lung illnesses such as chronic obstructive pulmonary disease (COPD) made up 7.7% of Medicare hospice decedents’ terminal conditions in 2023, according to a recent joint report by the Alliance and the Research Institute for Home Care.

“[With the] number of Medicare hospice users, we are seeing major increases over years, as you expect with an aging population,” Ware said during a recent webinar. “But when we’re looking at length of stay by diagnosis, the hospice benefit is ever-changing. The care providers provide is changing to meet patients where they’re at.”

Key hospice findings

The webinar discussion highlighted results from the joint report, dubbed the 2024 Hospice Chartbook, which examined Medicare hospice decedent trends during 2023. The report identified that roughly 6,500 Medicare-certified hospices provided services nationwide that year.

Approximately 52% of the 2.5 million Medicare decedents utilized the hospice benefit in 2023, the report found. While most states’ hospice utilization rates reached 50% to 55% on average, a few regions had lower levels compared to others such as Alaska, New York and Washington D.C., according to the findings.

Florida, Rhode Island and Utah held the highest rates, with hospice utilization reaching 60% or more across each of those states.

Researchers linked lower levels of hospice utilization to several factors including higher socioeconomic status of decedents, more physician visits in the last two years of life and fewer hospice resources within a geographic region.

The joint report found persistent racial, ethnic, regional and economic disparities among underserved patient populations. Roughly 86% of hospice decedents in 2023 were white, with minority groups making up the remaining portion. Additionally, about 18% of hospice patients that year were rural-based

Black patient populations were found to be among the least likely to utilize hospice services, according to Elizabeth Hamlet, senior consultant in evaluation and health economic practice at KNG Health Consulting. A multitude of potential barriers have hindered improved access and use, Hamlet indicated.

“Black beneficiaries specifically were less likely to utilize hospice care at the end of life, at 8.2%,” Hamlet said during the webinar. “This lower utilization could be due to mistrust of the medical field, or general misunderstanding or miscommunication of the hospice benefit.”

Length of stay challenges have also plagued the hospice industry for several years. The report found that more than half (52%) of hospice stays in 2023 were for less than one month, with only 29% lasting between one and six months. Median hospice length of stay rates ranged from 12 to 31 days that year.

Additionally, health care spending trends saw upward movement. Medicare hospice spending reached roughly $25.7 billion in 2023, which averaged roughly $186 in daily costs of care, the report found. This compared to about 2.7% in hospice costs of the $873 billion in overall Medicare spending that occurred during 2022.

These data can help inform hospices’ efforts to improve length of stay, according to Ware. The largest health care expenditures in hospice occur in the last days of life, representing an important area for providers to examine as they consider ways to ease cost-related constraints, she stated.

Honing focus around earlier goals-of-care conversations can be a significant strategic lever for hospices when communicating the value of their services to referrals and the public alike, Ware said. If hospice patients access these services sooner in their illness trajectories, the impacts could be substantial in terms of utilization and cost trends, she indicated.

“[It’s] trying to get additional information on what it would take to move patients from that shorter length stage to a little longer,” Ware said. “What kinds of decisions are made early on, and then making that difference. Is it conversations with families? Is it conversations with doctors? What does that impact look like for patients, organizations and the hospice benefit as a whole?”