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Demand for hospice climbs, but lengths of stay still low
Figures point to need for better marketing and education
Last February, a respected medical journal published a study that suggested non-cancer patients would be better served if they were admitted to hospice sooner. Days later, the National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA, released figures showing that a record number of people received hospice care in 2002, yet one-third of hospice patients died within one week of admission.
Hospice research published in the February issue of the Annals of Internal Medicine indicated savings of 7% to 17% could be realized for care of patients with aggressive forms of cancer. NHPCO data also revealed that length of service among cancer patients tends to be higher than among patients with other conditions, which improves cost-effectiveness.
"Hospice enrollment correlates with reduced Medicare expenditures among younger decedents with cancer but increased expenditures among decedents without cancer and those older than 84 years of age," researchers concluded. "Future studies should assess the effects of hospice on quality and on expenditures from all payment sources."
Earlier access to hospice care, both for people with cancer diagnoses and for those with non-cancer diagnoses, will bring superior end-of-life care to patients and their families and will improve the cost-effectiveness of hospice care, the NHPCO said in response to the study. Earlier access improves cost-effectiveness by reducing hospitalizations and utilization of expensive curative therapies that may offer little or no benefit to the patient, an NHPCO press release added.
"Hospice has always looked at each patient and family as a unique case requiring an individualized care plan," remarks J. Donald Schumacher, PsyD, president and CEO of the NHPCO. "Different illnesses require different services, and associated costs will vary, of course." Schumacher adds that his organization’s research "has shown that for a great many patients, hospice not only saves the health care system money but can also drastically reduce the financial impact for families while bringing them the care they want."
The other significant chunk of data comes from the NHPCO’s National Dataset, an ongoing project to track provider and access data. According to the Dataset’s latest figures, the nation’s 3,200 hospice providers served 885,000 dying Americans in 2002. The record number of patients served represents an increase of almost 15% from the 775,000 people cared for in 2001. More than 80% of hospice patients were Medicare beneficiaries, the NHPCO says.
The Dataset, along with NHPCO’s enhanced Family Evaluation of Hospice Care initiative, has been helpful in improving the industry’s understanding of how hospices serve the dying and their families, says the NHPCO.
The Dataset also reveals that one-third of hospice patients die within seven days of entering hospice. That means hospices must have sufficient time to develop a sound care plan that addresses physical and psychosocial issues and to establish trust within complex family relationships.
Hospice experts say one- to two-month stays would help avoid costly hospitalizations. Increasing access and length of service are key focuses for the industry these days.
"It’s essential that hospices serve patients and families as early as possible. Not only does this maximize the level of care and improve overall quality of life for patients, but it becomes more cost-effective for providers," says Schumacher. "Providing the best possible care is certainly the goal of all hospice care providers; however, an understanding of the cost-effectiveness of hospice is critical as our country faces a demographic shift of older Americans requiring care."
Data underscore need for education
The cost-effectiveness of hospice is not breaking news. In 1995, the landmark Lewin study commissioned by the NHPCO pointed out that for every dollar Medicare spent on hospice care, it saved $1.52. But at about the same time the hospice industry was touting the cost benefits of hospice, the industry also began to notice rapidly declining average and median lengths of stay. The percentage of hospice non-cancer admissions decreased dramatically in the 1990s. The drop in non-cancer admissions has been blamed on problems associated with determining a six-month prognosis for patients with non-cancer illnesses.
The study and NHPCO’s Dataset point to the need for better physician and patient education, two areas that have proven to be tough nuts to crack for hospices in general. Specifically, it points to the need for physician education in the following areas:
Prospective patients need help understanding:
A lack of understanding in any of the above areas amounts to a missed opportunity for hospices to increase patient access and length of stay.
"There is no short-term solution," says Margaret Clausen, executive director of the California Hospice and Palliative Care Association in Sacramento. "We’re talking about changing culture."
An obstacle to changing physician behavior is that physician memory isn’t short enough to forget the days when Medicare questioned a hospice admission if the patient survived longer than six months. A barrier to patient access is the fact that most people would rather not discuss death or dying, even after they have been diagnosed with a potentially terminal illness.
Hospices are aware of the barriers that have inhibited patient access to hospice, and the industry has made attempts to address these problems. Clausen points to her own state, where hospice-friendly laws have been passed. Lobbying by industry leaders has persuaded Medicare officials to make public statements regarding terminal illness certification, and physician groups are trying to change the culture of their profession.
For instance, Education for Physicians on End-of-life Care (EPEC) has provided train-the-trainer programs to thousands of physicians in the hope that they will encourage better end-of-life care among their peers. EPEC was developed by the American Medical Association and originally funded by a grant from The Robert Wood Johnson Foundation. Northwestern University Medical School now sponsors the project. It is designed to educate physicians on the essential clinical competencies required to provide quality end-of-life care.
EPEC consists of a core curriculum that gives physicians the basic knowledge and skills needed to provide appropriate care for dying patients. The EPEC curriculum consists of four 30-minute plenary modules and 12 45-minute workshop modules that are transportable and self-contained. EPEC teaches fundamental skills in communication, ethical decision-making, palliative care, psychosocial considerations, and pain and symptom management.
"Our experience with EPEC has been that physicians who come get a lot out of it, but change is slow," says Clausen.
Although efforts have been slow to bear fruit, that doesn’t mean hospices should wait until change occurs. Clausen says local hospices need to work with physicians in their own communities. She recommends the following: