Association between the Medicare hospice benefit and health care utilization and costs for patients with poor-prognosis cancer

Abstract

Importance: More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it.

Objective: To compare utilization and costs of health care for patients with poor-prognosis cancers enrolled in hospice vs similar patients without hospice care.

Design, setting, and participants: Matched cohort study of patients in hospice and nonhospice care using a nationally representative 20% sample of Medicare fee-for-service beneficiaries who died in 2011. Patients with poor-prognosis cancers (eg, brain, pancreatic, metastatic malignancies) enrolled in hospice before death were matched to similar patients who died without hospice care.

Exposures: Period between hospice enrollment and death for hospice beneficiaries, and the equivalent period of nonhospice care before death for matched nonhospice patients.

Main outcomes and measures: Health care utilization including hospitalizations and procedures, place of death, cost trajectories before and after hospice start, and cumulative costs, all during the last year of life.

Results: Among 86,851 patients with poor-prognosis cancers, median time from first poor-prognosis diagnosis to death was 13 months (interquartile range [IQR], 3-34), and 51,924 patients (60%) entered hospice before death. Matching yielded a cohort balanced on age, sex, region, time from poor-prognosis diagnosis to death, and baseline care utilization, with 18,165 patients in the hospice group and 18,165 in the nonhospice group. After matching, 11% of nonhospice and 1% of hospice beneficiaries who had cancer-directed therapy after exposure were excluded. Median hospice duration was 11 days. After exposure, nonhospice beneficiaries had significantly more hospitalizations (65% [95% CI, 64%-66%], vs hospice with 42% [95% CI, 42%-43%]; risk ratio, 1.5 [95% CI, 1.5-1.6]), intensive care (36% [95% CI, 35%-37%], vs hospice with 15% [95% CI, 14%-15%]; risk ratio, 2.4 [95% CI, 2.3-2.5]), and invasive procedures (51% [95% CI, 50%-52%], vs hospice with 27% [95% CI, 26%-27%]; risk ratio, 1.9 [95% CI, 1.9-2.0]), largely for acute conditions not directly related to cancer; and 74% (95% CI, 74%-75%) of nonhospice beneficiaries died in hospitals and nursing facilities compared with 14% (95% CI, 14%-15%) of hospice beneficiaries. Costs for hospice and nonhospice beneficiaries were not significantly different at baseline, but diverged after hospice start. Total costs over the last year of life were $71,517 (95% CI, $70,543-72,490) for nonhospice and $62,819 (95% CI, $62,082-63,557) for hospice, a statistically significant difference of $8697 (95% CI, $7560-$9835).

Conclusions and relevance: In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care unit admission, and invasive procedures at the end of life, along with significantly lower total costs during the last year of life.

Figure 1. Matching of Hospice to Nonhospice Beneficiaries

^aNationally representative 20% sample (74% of the Medicare population, excluding those enrolled in managed care). ^bIndicates that recorded date of death was before the poor-prognosis diagnosis date or the hospice start date. Matching stage B shows exposure periods for 2 hypothetical beneficiaries matched in the first stage. In chronological time, the 2 beneficiaries are represented as lines spanning from poor-prognosis diagnosis to death; in the exposure time frame used for analysis, dates of death are aligned to create a similar exposure period of hospice or nonhospice care prior to death. Because beneficiaries are matched on time from diagnosis to death, the lengths of the lines are approximately the same. After matching exposure periods, we dropped pairs in which one or both beneficiaries received chemotherapy or curative surgery during the periods.

Figure 2. Cost Trajectories Before and After Hospice Start

Graphs show mean total daily costs relative to hospice start, with beneficiaries separated into groups based on the length of the exposure period (ie, the length of hospice or nonhospice care before death). Because showing all 109 groups was not possible and aggregation would obscure time trends, we show representative groups with exposure periods of 1, 2, 3, and 4 weeks, which together make up 71% of the entire cohort; every 2 weeks from 6 to 12 weeks (8% of the cohort); and every 4 weeks from 16 to 28 (2%). Circles mark week of death for each group of beneficiaries. The shaded area around the lines indicate the 95% CIs for the mean; lower CI bounds of less than zero were censored at zero. Week zero is defined as the week before the first day of hospice.