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					  Hospice
  Brad Chase
Heather Goodroe
   Oren Kiriat
 Aimee Reeves
 Melissa Wahl
              HOSPICE
Palliative care vs. intensive/invasive care
Health Benefits
Availability
Added Utility?
Cost-Effectiveness
         Employer Support
Insurance Benefit Plans
   - Affordable
   - Comprehensive
Focus Groups
   -1,502 Employers with 200 or more
          employees
Coverage
   -83% of employees with explicit
          hospice benefits
   -High Cost Case Management
   Employer Support (cont…)

Hospice Benefits
       -Attitude
       -Knowledge
       -Performance Measurement
Number of Medicare Hospice
  Benefit Users (’92-’98)
General Accounting Office (GAO)
Use of hospice by non-cancer patients has
increased 338%
– 43% of beneficiaries using hospice are non-
  cancer patients
– Physicians are reluctant to refer patients for
  hospice service
– Referrals are often delayed until latter stages
  of disease
 Decline in Average and Median
Hospice lengths of service (’92-’98)
General Accounting Office (GAO)
Providers report that shorter lengths of
stay have created increased cost
pressures
– The more severe case mix requires more
  intense (and expensive) care
– More types of care are demanded (radiation
  and chemotherapy for pain)
– Fewer days to offset high costs at admission
  and immediately prior to death
Medicare beneficiaries' costs of
  care in the last year of life
Some statistics
-   61% of health care costs in last year of life are
    covered by Medicare
-   25% of Medicare expenses are attributable to
    last year of life
-   19% of Medicare enrollees utilize hospital
    services
-   Medicare spending in last year of life is 27%
          Medicare’s role

Outlays are stable part of total spending
End of life policy should include
coordination of acute, long term and
hospice benefits between
Medicare/Medicaid
New policies should emphasize end of life
care in benefit design
            Hospice care

Hospice primarily for cancer patients
Not an option for many because of hard to
predict life spans
Lack of care produces costly gap
Patients not in MC and not dying of cancer
have very little support
Providing care at the end of life: Do
Medicare rules impede good care?
 Providers believe that the hospice
 reimbursement rate is not high enough to meet
 demands for current treatments.
 This may be leading to denial of services to
 those with high-cost care demands.
 Per day expenses are typically higher in the first
 days of hospice care, and at the end. Shorter
 lengths of stay have contributed to budget
 shortfalls of 5-12% for 8 of the 10 hospices
 studied.
 Federal scrutiny regarding the eligibility rule of a
 prognosis of 6 months or less contributed to the
 delay in referrals.
Do Medicare Rules Impede Good
        Care?…cont.
Larger or chain hospices are better able to
manage costs through contracting.
“Thrivers” - Forced discharge when prognosis is
more than 6 months creates higher costs since
the patient usually improves for a short time.
Some private insurers implement caps or do not
cover hospice at all. Commercial plans often
carve out the higher cost treatments and pay
separate FFS rates for them.
    Article Recommendations:
Adopt a patient outlier payment policy,
similar to hospital DRG policy.
Readjust per diem rates to include new
treatments and demands
Pay a higher per diem for the first and last
days of care
Determine how hospice care will be
affected by the prescription drug benefit
Consider using capitation payments to
control cost.
Including Hospice in Medicare capitation
   payments: Would it save money?

    HMO vs. FFS - Hospice enrollment in the last
    calendar month of life
    HMO vs. FFS mortality rates
    Comparing estimated actual Medicare
    payments on behalf of risk-based HMO
    enrollees with simulated Medicare payments
    for the same enrollees assuming the inclusion
    of Hospice in Medicare capitation payments.
HMO vs. FFS - Hospice enrollment in
  the last calendar month of life

  27.0 percent of risk-based HMO decedents were
  enrolled in a hospice during their last month of
  life
  19.4 percent of FFS decedents were enrolled in
  a hospice during the last month of life
  Differences were statistically significant
  (p<0.001)
  HMO vs. FFS mortality rates


Beneficiaries in a risk-based HMO
demonstrated a lower mortality rate than
among beneficiaries in FFS
Comparing actual Medicare payments
 with simulated Medicare payments

  When total actual payments for July 1998 were
  compared with the simulated total payments
  assuming capitation of hospice services, a $1.9
  million difference was observed.
  This difference represents only 0.07 percent of
  actual payments for risk-based enrollees.
  The estimated savings equaled approximately
  $23 million per year.
   Conclusions and Questions


The aging population and Hospice
Quality of Care
Gaps in Care
Availability and utilization patterns
The future of Hospice care
Questions?

				
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posted:9/10/2011
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