Trends and Characteristics of Medicare Hospice Beneficiaries in the USA
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J Gen Intern Med DOI: 10.1007/s11606-020-06288-x © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2020
BACKGROUND
Hospice provides critical support to patients and caregivers at the end of life with 48% of deaths among Medicare hospice beneficiaries occurring at home.1 This program was originally designed primarily for cancer patients with a relatively predictable end-of-life trajectory. However, the American population has changed, as have medical treatments and hospice admission criteria.
OBJECTIVE
We sought to assess changes in hospice care and hospice beneficiaries using publicly available data from 2014 to 2017.
METHODS AND FINDINGS
We analyzed de-identified data from the CMS Fee-ForService Post-Acute Care Provider Public Use Files from 2014 through 2017.2 The primary data source is the CMS Chronic Condition Data Warehouse with 100% of Medicare enrollment and fee-for-service claims data. To assess differences between 2014 and 2017, analysis of variance was used for continuous variables while logistic regression was used for categorical variables. The number of Medicare beneficiaries using hospice increased from 1,367,114 in 2014 to 1,545,509 in 2017 (+ 13.0%), representing 45.7% and 48.2% of all Medicare decedents respectively.1 Amongst Medicare hospice beneficiaries in 2017, average age was 82.4 years, 58.2% were female, and 82.3% were white (Table 1). The number of days in hospice increased from 91,909,774 in 2014 to 106,387,029 in 2017 (+ 15.8%), and the percentage of days during which routine home care was delivered also increased as did the rate of live discharge from hospice care. During that period, hospice length of service also grew longer, and Medicare Advantage and Medicaid enrollees increased. Total Medicare payments Received June 19, 2020 Accepted October 5, 2020
increased from $15.1 billion US dollars to $17.9 billion US dollars (+ 18.5%). However, while both Medicare payments per diem ($163.82 to $168.41) and per beneficiary ($11,013.62 to 11,593.62) increased, home health and skilled nursing visits in the last week of life decreased (all p < 0.0001). A downward trend was observed in the proportion of hospice beneficiaries with a primary diagnosis of cancer, dementia, and respiratory illness, while the number of stroke patients increased. The proportion of patients with heart disease remained largely unchanged. There was a slight increase in the proportion of minority hospice enrollees.
DISCUSSION
As hospice use continues to grow, our data shows a decrease in the proportion of patients with cancer enrolled in hospice with an increase in patients with other conditions such as stroke. Second, even though there was an increase in costs, decreases were noted in nursing visits and the proportion of patients receiving higher intensity care. The findings of growth in hospice use and cost amongst Medicare beneficiaries build on findings from a recent MedPAC report and could reflect the
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