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


METHODS
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.


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


METHODS
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
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.
Departments of Emergency Medicine and Health Care Policy, Harvard Medical School, Boston, Massachusetts2Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Ariadne Labs, Brigham and Women's Hospital and Harvard School of.
Ziad
Z
Obermeyer
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Maggie
M
Makar
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Samer
S
Abujaber
Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts.
Francesca
F
Dominici
Ariadne Labs, Brigham and Women's Hospital and Harvard School of Public Health, Boston, Massachusetts5Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts6Department of Psychiatry, Brigham and Women'
Susan
S
Block
Department of Economics, Harvard University, Cambridge, Massachusetts9National Bureau of Economic Research, Cambridge, Massachusetts.
David M
DM
Cutler
D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003422:Critical Care / Q000191:economics / Q000706:statistics & numerical data; D018588:Fee-for-Service Plans; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006296:Health Services / Q000191:economics / Q000706:statistics & numerical data*; D017051:Hospice Care / Q000191:economics*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000191:economics*; D009369:Neoplasms / Q000191:economics* / Q000628:therapy; D011379:Prognosis; D012189:Retrospective Studies; D013727:Terminal Care / Q000191:economics*; D014481:United States