A great challenge in the care of demented patients under hospice care is the issue of prognosis. Patients become eligible for hospice services when a referring physician and a hospice doctor agree that the patient will probably live no longer than six months. It is fairly easy to predict that end- stage cardiac, pulmonary, and cancer patients will die in the six month period that conforms to Medicare prognostic guidelines, but this is not the case with dementia. I have had demented patients under my care for years, even though they are helpless and have no apparent cognitive function.
Medicare requires that a physician (or a nurse practitioner under the supervision of a physician) “recertify,” with a personal visit, patients’ continued eligibility after six months on hospice, and every two months thereafter. If there is no sign of deterioration (recent infection, development of bed sores, apparent worsening of pain and/or anxiety, diminishing appetite, and the like), we are supposed to “discharge” the patient from hospice care. This is true even though the patient would qualify for hospice care if he/she were being newly evaluated.
This in-person recertification requirement came into effect a few years ago, and Medicare says it is a rule designed for quality care. But if this were true, Medicare should require that patients newly admitted to hospice be seen by a hospice physician in a timely fashion. This is not the case, and in fact no personal hospice physician visit is mandated until the six month milestone. It seems obvious the recertification process is designed to save money.
But just how costly is hospice? In a previous post, I documented the ever increasing usage and expense to the government of hospice services (almost all hospice patients receive benefits at no charge). This has caused some healthcare economists to decry these burgeoning expenditures. But the case can be made that hospice is a money saver, and in fact a healthcare analytics data firm has done just that. A 2019 study found that patients who did not choose the hospice benefit incurred as much as $27,455 in additional healthcare costs, compared with patients who received hospice care in their last months of life.
What is going on? With the wide availability of hospice services, families and patients are increasingly choosing to forgo aggressive medical care when the end of life is obviously near. This has increased the national hospice bill considerably, but there is more than an equal decrease in overall expenditure for Medicare hospitalizations, including useless, and often painful, interventions.
Hospice is a wildly popular program with satisfaction surveys that are off the charts, and it is a critically important service regardless of the cost. But there is also a net savings to our healthcare system with hospice. Apparently unable to see the overall savings, some Medicare analysts suffer from a “silo” mentality that obfuscates good decision making.
Hospice services are still underutilized–oncology societies estimate that as many as 50 percent of terminal cancer patients who would benefit from hospice do not get enrolled in the program and/or get enrolled at a time near death, which deprives them of the full force of hospice services. Rather than worrying about threats to Medicare’s bottom line, and making criteria for qualifying for hospice services more stringent, the bean counters should be looking for ways to increase hospice usage.