Association between Hospice Spending on Patient Care and Rates of Hospitalization and Medicare Expenditures of Hospice Enrollees

Private Equity Acquisitions Of Hospices Are Increasing; Ownership Remains Opaque

Private equity ownership across the US health care system is rapidly increasing, yet ownership structures are complex and opaque. We used an economic data set tracking mergers and acquisitions linked to Medicare data to identify private equity hospice acquisitions. Given the influence of for-profit ownership on hospice quality, transparent data on private equity investment are fundamental to ensuring high-quality end-of-life care.

Association of Hospice Profit Status With Family Caregivers' Reported Care Experiences

Importance

Expansive growth in the US hospice market has been driven almost exclusively by an increase in for-profit hospices. Prior research found that, in contrast to not-for-profit hospices, for-profit hospices focus on delivering care to patients in nursing homes, provide fewer nursing visits, and use less skilled staff. However, prior studies have not reported on the associations of these differences in care patterns with hospice care quality. Patient- and family-centeredness is a core element of hospice care quality that is measured through surveys of care experiences.

Objective

To examine whether differences in profit status are associated with family caregivers' reports of hospice care experiences and assess factors that may be associated with observed differences in care experiences by profit status.

Design, Setting, and Participants

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from 653 208 caregiver respondents, reflecting care received from 3107 hospices between April 2017 and March 2019, were used for a cross-sectional examination of hospice care experiences by profit status. Data analysis was performed from January 2020 to November 2022.

Main Outcomes and Measures

Outcomes were case-mix-adjusted and mode-adjusted top-box scores for 8 measures of hospice care experiences, including communication, timely care, symptom management, and emotional and religious support, as well as a summary score averaging across measures. Linear regression examined the association between profit status and hospice-level scores, adjusting for other organizational and structural hospice characteristics.

Results

There were 906 not-for-profit and 1761 for-profit hospices with mean (SD) time in operation of 25.7 (7.8) years and 13.8 (8.0) years, respectively. Mean (SD) decedent age at death was 82.8 (2.3) years, similar for not-for-profit and for-profit hospices. The mean proportion of patients who were Black, Hispanic, and White was 4.9%, 0.9%, and 91.4% for not-for-profit hospices and 9.0%, 2.2%, and 85.4% for for-profit hospices, respectively. Family caregivers reported worse care experiences at for-profit hospices than at not-for-profit hospices for all measures. Significant differences in average hospice performance by profit status remained after adjusting for hospice characteristics. However, for-profit hospice performance varied, with 548 of 1761 (31.1%) for-profit hospices scoring 3 or more points below the national hospice average of overall performance and 386 of 1761 (21.9%) scoring 3 or more points above the average. In contrast, only 113 of 906 (12.5%) not-for-profit hospices scored 3 or more points below the average, and 305 of 906 (33.7%) scored 3 or more points above the average.

Conclusions and Relevance

In this cross-sectional study of CAHPS Hospice Survey data, caregivers of patients receiving hospice care reported substantially worse care experiences in for-profit than in not-for-profit hospices; however, there was variation in reported experiences among both types of hospices. Public reporting of hospice quality is important.

Cost-Effectiveness Analysis of Home-Based Hospice-Palliative Care for Terminal Cancer Patients

Purpose

We compared cost-effectiveness parameters between inpatient and home-based hospice-palliative care services for terminal cancer patients in Korea.

Methods

A decision-analytic Markov model was used to compare the cost-effectiveness of hospice-palliative care in an inpatient unit (inpatient-start group) and at home (home-start group). The model adopted a healthcare system perspective, with a 9-week horizon and a 1-week cycle length. The transition probabilities were calculated based on the reports from the Korean National Cancer Center in 2017 and Health Insurance Review & Assessment Service in 2020. Quality of life (QOL) was converted to the quality-adjusted life week (QALW). Modeling and cost-effectiveness analysis were performed with TreeAge software. The weekly medical cost was estimated to be 2,481,479 Korean won (KRW) for inpatient hospice-palliative care and 225,688 KRW for home-based hospice-palliative care. One-way sensitivity analysis was used to assess the impact of different scenarios and assumptions on the model results.

Results

Compared with the inpatient-start group, the incremental cost of the home-start group was 697,657 KRW, and the incremental effectiveness based on QOL was 0.88 QALW. The incremental cost-effectiveness ratio (ICER) of the home-start group was 796,476 KRW/QALW. Based on one-way sensitivity analyses, the ICER was predicted to increase to 1,626,988 KRW/QALW if the weekly cost of home-based hospice doubled, but it was estimated to decrease to -2,898,361 KRW/QALW if death rates at home doubled.

Conclusion

Home-based hospice-palliative care may be more cost-effective than inpatient hospice-palliative care. Home-based hospice appears to be affordable even if the associated medical expenditures double.

Rural disparities in end-of-life care for patients with heart failure: Are they due to geography or socioeconomic disparity?

PURPOSE

The impact of rurality and socioeconomic deprivation on end-of-life (EOL) care for patients with heart failure (HF) is unknown. We analyzed claims to describe the prevalence and predictors of EOL health care utilization for patients dying with HF in a predominantly rural state.

METHODS

We used the MaineHealth Data Organization's All-Payer Claims Data to identify 15,168 patients ≥35 who died with HF between 2012 and 2017. The primary outcome was health care utilization during the last 180 days of life (EOL definition for this analysis), including emergency department (ED) visits, hospitalizations, intensive care unit (ICU) admissions, and hospice utilization. Patient characteristics analyzed included age, gender, comorbidities, area deprivation index (ADI), and rurality.

FINDINGS

Among 15,168 patients ≥35 who died with HF, 48% had ≥2 hospitalizations, 72% had ≥2 ED visit, 29% had an ICU stay, 2% initiated dialysis during EOL, and 64% received hospice. Rural patients were more likely to have an ICU admission and have ≥2 hospitalizations. Patients residing in areas with higher ADI were more likely to be hospitalized, admitted to the ICU, and started on dialysis. Both rural patients and those living in higher ADI areas were less likely to receive hospice. After multivariable adjustment, rurality and ADI were independently associated with a decreased likelihood of receiving hospice (OR 0.62 [95% CI: 0.53-0.72] for the most rural patients and OR 0.64 [95% CI: 0.57-0.72] for the highest ADI).

CONCLUSION

Both rurality and local area deprivation drive disparities in EOL care for patients dying with heart failure.

The Effect of Hospice on End-of-Life Costs for Terminal Medicare Patients With HIV

One-quarter of annual Medicare expenses in the traditional program (non-Medicare Advantage) are expended for 5% of Medicare enrollees, with much of this expenditure occurring in the last year of life. Hospice use may reduce end-of-life costs. However, evidence has been inconclusive due to sample selection and differences in insurance coverage for hospice. Claims data for HIV-positive Californians enrolled in Medicare who died in the period 2008 to 2010 were used to examine the relationship between hospice use and costs in the last 6 months of life. Logit estimates related hospice use to sickness levels and demographics. Inpatient and outpatient costs were analyzed separately. Logit regressions examined hospitalization probability. Robust regressions were used to examine the determinants of conditional inpatient costs and non-inpatient costs. Bootstrapped post-estimates were then used to determine the marginal probability of costs for the sample by hospice use. Hospice users have greater disease burden and are less likely to be African American. Controlling for disease burden, hospice users would have non-inpatient costs that were $14 771 greater than hospice non-users, but inpatient costs that were $20 522 lower. Thus, hospice reduces costs on net. Hospice is chosen by patients with more comorbidities. Controlling for these comorbidities, hospice use is associated with lower inpatient costs, greater non-inpatient costs and reduced end-of-life costs.

Predictors of reliably high-value end-of-life care

PURPOSE OF REVIEW

Care near the end of life is expensive and frequently not aligned with the expressed preferences of decedents, creating an opportunity to improve value, or increase quality while lowering cost. This review examines publications from 2017 and 2018 on interventions and policies associated with high-value end-of-life care. Innovations in video and web-based advance care planning are promising to improve preference-congruent care at low cost.

RECENT FINDINGS

The patterns of care within hospice and in particular increased investment in patient care in hospice are shown to improve value. A meta-analysis demonstrated the role of inpatient palliative care consultations in decreasing hospitalization costs, as did several studies on inpatient palliative care units. Internationally, a range of home-based palliative care programs, implemented at the population level, demonstrated cost savings and reduced intensive care near the end of life. Finally, public policies that funded medical and long-term care and address broader inequalities were demonstrated to decrease low-value care near the end of life.

SUMMARY

This review demonstrates the efficacy of a range of approaches to improve value of care at the end of life, both within the health system and across public policy sectors.

Have Hospice Costs Increased After Implementation of the Hospice Quality-Reporting Program?

CONTEXT

The Centers for Medicare & Medicaid Services Hospice Quality-Reporting Program introduced the requirement that hospices nationwide begin collecting and submitting standardized patient-level quality data on July 1, 2014.

OBJECTIVES

This study examined whether this requirement has increased hospice total costs, general costs, and visiting services costs.

METHODS

We conducted a cross-sectional study using data from the 2012 and 2014 Medicare hospice cost reports linked to hospice claims. We measured total costs per patient day (PPD), general costs PPD, and visiting services costs PPD for freestanding hospices. We estimated the incremental costs of operating in 2014 vs. 2012 using hierarchical random effects models and adjusting for year, wage index, care volume, case-mix, and hospice and market characteristics, stratified by hospice ownership type.

RESULTS

Both for-profit and nonprofit hospices reported higher total costs PPD and general services costs PPD in 2014 than 2012. Nonprofit hospices also reported higher general costs PPD in 2014 than 2012. In adjusted models, the total costs PPD in 2014 were $10.55 higher than in 2012 for nonprofit hospices and $6.43 higher for for-profit hospices. The increase in general costs PPD and visiting services costs PPD ranged from $3.15 to $5.87 by ownership and type of costs. Both for-profit and nonprofit hospices showed lower costs PPD for all types associated with more patients and longer length of stay.

CONCLUSION

Hospice costs increased after the Centers for Medicare & Medicaid Services Hospice Quality-Reporting Program quality data collection/submission requirement. Complementary studies need to understand whether increased costs brought additional benefits.

Predictors of Hospice Enrollment for Patients With Advanced Heart Failure and Effects on Health Care Use

OBJECTIVES

This study sought to: 1) identify the predictors of hospice enrollment for patients with heart failure (HF); and 2) determine the impact of hospice enrollment on health care use.

BACKGROUND

Patients with HF rarely enroll in hospice. Little is known about how hospice affects this group's health care use.

METHODS

Using a propensity score-matched sample of Medicare decedents with ≥2 HF discharges within 6 months, an Outcome and Assessment Information Set (OASIS) assessment, and subsequent death, we used Medicare administrative, claims, and patient assessment data to compare hospitalizations, intensive care unit stays, and emergency department visits for those beneficiaries who enrolled in hospice and those who did not.

RESULTS

The propensity score-matched sample included 3,067 beneficiaries in each group with a mean age of 82 years; 53% were female, and 15% were Black, Asian, or Hispanic. For objective 1, there were no differences in the characteristics, symptom burden, or functional status between groups that were associated with hospice enrollment. For objective 2, in the 6 months after the second HF discharge, the hospice group had significantly fewer emergency department visits (2.64 vs. 2.82; p = 0.04), hospital days (3.90 vs. 4.67; p < 0.001), and intensive care unit stays (1.25 vs. 1.51; p < 0.001); they were less likely to die in the hospital (3% vs. 56%; p < 0.001), and they had longer median survival (80 days vs. 71 days; log-rank test p = 0.004).

CONCLUSIONS

Beneficiaries' characteristics, including symptom burden and functional status, do not predict hospice enrollment. Those patients who enrolled in hospice used less health care, survived longer, and were less likely to die in the hospital. A tailored hospice model may be needed to increase enrollment and offer benefits to patients with HF.

Racial Disparities in Hospice Outcomes: A Race or Hospice-Level Effect?

OBJECTIVES

To determine whether there is racial variation in hospice enrollees in rates of hospitalization and hospice disenrollment and, if so, whether systematic differences in hospice provider patterns explain the variation.

DESIGN

Longitudinal cohort study.

SETTING

Hospice.

PARTICIPANTS

Medicare beneficiaries (N = 145,038) enrolled in a national random sample of hospices (N = 577) from the National Hospice Survey and followed until death (2009-10).

MEASUREMENTS

We used Medicare claims data to identify hospital admissions, emergency department (ED) visits, and hospice disenrollment after hospice enrollment. We used a series of hierarchical models including hospice-level random effects to compare outcomes of blacks and whites.

RESULTS

In unadjusted models, black hospice enrollees were significantly more likely than white enrollees to be admitted to the hospital (14.9% vs 8.7%, odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.74-1.95), visit the ED (19.8% vs 13.5%, OR = 1.58, 95% CI = 1.50-1.66), and disenroll from hospice (18.1% vs 13.0%, OR = 1.48, 95% CI = 1.40-1.56). These results were largely unchanged after accounting for participant clinical and demographic covariates and hospice-level random effects. In adjusted models, blacks were at higher risk of hospital admission (OR = 1.75, 95% CI = 1.64-1.86), ED visits (OR = 1.61, 95% CI = 1.52-1.70), and hospice disenrollment (OR = 1.54, 95% CI = 1.45-1.63).

CONCLUSION

Racial differences in intensity of care at the end of life are not attributable to hospice-level variation in intensity of care. Differences in patterns of care between black and white hospice enrollees persist within the same hospice.