How many Medicare beneficiaries use hospice care at end of life?

During 2004, hospice was used at the end of life by almost four of 10 Medicare beneficiaries enrolled in managed care plans and by three of 10 of those in traditional Medicare. Hospice use increased to a similar degree among those in both arrangements from 1998 to 2004. Hospice use varies widely among the states.

Why is this important?

Hospice is not a place but an approach to care that seeks to maintain the comfort of a dying person, rather than seek a cure for illness. While hospice care is increasingly provided in nursing homes, it is also frequently provided to terminally ill patients at home, where most people say they would prefer to die (Tang 2003). Since 1983, Medicare has covered hospice care for beneficiaries whose doctors certify that they have a life expectancy of six months or less (MedPAC 2004).

Findings

From 1998 to 2004, hospice use increased among Medicare beneficiaries who died. It nearly doubled, from 16 percent to 30 percent, among those in traditional, fee-for-service Medicare. It increased by about one-half, from 25 percent to 38 percent, among those in Medicare managed care plans (MedPAC 2004, 2006).

Among Medicare beneficiaries with severe chronic illnesses who died during 2000–2003 (and were likely candidates for hospice), rates of hospice use in the last six months of life varied substantially by state: from 7 percent in Alaska to 45 percent in Arizona (Dartmouth Atlas Project 2006).

Implications

Increasing use of hospice among Medicare beneficiaries may reflect better understanding of its benefits. Although hospice is used most often by cancer patients, it is increasingly used by those with other life-threatening chronic illnesses such as dementia and heart disease (MedPAC 2006).

The reasons for higher use of hospice among beneficiaries in managed care plans are not known but "may reflect a variety of factors, including patient preference for care and financial incentives for managed care plans to refer patients to hospice" (MedPAC 2004). A study of cancer patients "found no evidence to suggest that managed care organizations are conserving their resources by enrolling patients in hospice care inappropriately" (McCarthy et al. 2003).

Improvement Ideas and Resources

The Medicare Modernization Act of 2003 includes provisions that may increase the use of hospice, including coverage for a one-time consultation session to evaluate a patient's eligibility and need for hospice care (HCFO 2004).

Measure:

For overall annual rates of hospice use, the denominator is a 5 percent sample of Medicare beneficiaries who died during the given year, stratified by enrollment in traditional (fee-for-service) Medicare or a managed care plan. The numerator is the subset of the denominator population who used hospice (MedPAC 2004, 2006).

For state rates, the denominator is a 20 percent sample of traditional (fee-for-service) Medicare beneficiaries who died during the four-year period 2000–2003, who were residents of a given geographic area at the date of death, and who were diagnosed with at least one of 12 chronic illnesses (cancer, lymphoma and leukemia, chronic pulmonary disease, coronary artery disease, congestive heart failure, peripheral vascular disease, severe chronic liver disease, diabetes with end organ damage, chronic renal failure, nutritional deficiencies, dementia, and functional impairment). The numerator is the subset of the denominator population enrolled in hospice during the last six months of life. Rates are adjusted to account for differences in patients' age, sex, race, and prevalence of the 12 chronic illnesses (Dartmouth Atlas Project 2006).

Limitations:

These data do not measure appropriateness of care, unmet need for hospice care, or how well Medicare beneficiaries were educated about the availability of the hospice benefit.

Source:

Overall rates of hospice use were calculated by the Medicare Payment Advisory Commission using the Medicare enrollee database (MedPAC 2004, 2006). State rates were calculated by researchers at Dartmouth Medical School's Center for Clinical Evaluative Sciences using Medicare denominator files and standard analytic files (Dartmouth Atlas Project 2006).

References:

* Indicates source of data used in the chart(s).

* Dartmouth Atlas Project. 2006. The Care of Patients with Severe Chronic Illness: An Online Report on the Medicare Program. Hanover, N.H.: Dartmouth Medical School, Center for the Evaluative Clinical Sciences.

HCFO (Changes in Health Care Financing and Organization). 2004. Medicare Modernization Act Offers New End-of-Life Care Provisions. Washington, D.C.: AcademyHealth.

McCarthy, E. P., R. B. Burns, Q. Ngo-Metzger et al. 2003. Hospice Use Among Medicare Managed Care and Fee-for-Service Patients Dying with Cancer. Journal of the American Medical Association 289 (17): 2238–45.

* MedPAC. 2004. Hospice Care in Medicare: Recent Trends and a Review of the Issues. Chapter 6. In Report to the Congress: New Approaches in Medicare, 139–153. Washington, D.C.: Medicare Payment Advisory Commission.

* MedPAC. 2006. Medicare's Hospice Benefit: Recent Trends and Consideration of Payment System Refinements. Chapter 3. In Report to the Congress: Increasing the Value of Medicare, 59–75. Washington, D.C.: Medicare Payment Advisory Commission.

Tang, S. T. 2003. When Death Is Imminent: Where Terminally Ill Patients with Cancer Prefer to Die and Why. Cancer Nursing 26 (3): 245–51.