Posted On: February 27, 2013 by Patrick A. Malone

Medicare Provides More Hospice Care, but Also More Hospital Overtreatment

In a good news/bad news scenario about end-of-life care, more people older than 65 are dying in hospice care and fewer are dying in hospitals, but patients also are hospitalized more frequently in the last three months of their lives. They’re also more likely to spend time in intensive care units, and frequently receive hospice care for only a matter of days before they die.

The study was published recently in the Journal of the American Medical Association (JAMA), and widely interpreted throughout the media, including on Forbes.com. Although the increasing use of hospice is a welcome development in health care, the problem is that where somebody dies doesn’t say much about how he or she was cared for in the final weeks of life.

This study paints a far more disappointing picture of that—nearly 30 in 100 hospice users were enrolled for three days or fewer.

A patient might spend the last couple of days under hospice care, whose mission isn’t to test or treat, but simply make the patient the most comfortable he or she can be. But right before being moved to that welcoming environment, many patients were subjected to invasive hospital care, often in the intensive care unit. Sometimes in the last days or weeks of life, patients were shuttled among home, hospital, nursing home and back to the hospital.

That situation is seldom good for anybody. As one of our blogs last year discussed, our culture extends the lives of the elderly and the terminal by taking extreme measures often beyond what patients desire or families understand. That essay contrasts those common practices with what doctors themselves generally choose for their end-of-life experience.

As reported by Forbes, the Centers for Disease Control and Prevention (CDC) recently found that more people are dying at home. And Medicare is considering that where somebody dies might be a quality measure for end-of-life care on the theory that it’s less stressful than dying in an institution.

The JAMA study showed that about 1 in 3 Medicare beneficiaries died at home in 2009, 10 percent more than in 2000. Only about 1 in 4 died in the hospital in 2009, down 25 percent from 2000. The ratio of people who died in nursing homes remained about the same. But about 42 in 100 people died in hospice care in 2009, nearly double the numbers in 2000.

But moving from one care setting to another in the last 90 days of life increased by half—from about two moves in 2000 to three in 2009. One in 10 patients was moved (known as a “care transition”) in his or her last three days in 2000, but 14 in 100 were moved in 2009. About 1 in 4 people who died used the ICU in 2000, and nearly 30 in 100 did in 2009. More than 1 in 10 had three or more hospitalizations in the last 90 days of their life.

These patients spent slightly less time in the hospital, but they spent more time in the ICU, where treatment is most invasive and intense. Dementia patients spent more time in the intensive care in 2009 than in 2000.

To learn more about how to protect your interests when you’re hospitalized and unable to communicate, see my newsletter, “Talking to Your Doctor When You Can’t Speak.”

As Forbes explains, the JAMA study isn’t conclusive—it involved only patients in traditional fee-for-service Medicare, not Medicare Advantage plans, which are provided by private insurers and offer broader coverage. And the study looks retrospectively at all patients who have died, even those who would not have been expected to receive end-of-life care; for example, an otherwise healthy senior who has an accident with fatal complications. It might have been appropriate for that person to have been transitioned through several levels of care, unlike other patients whose situations led them to be overtreated.

But most people don’t die in those unforeseen ways. They suffer from chronic diseases or dementia, and death often is not a surprise. The study, says Forbes, “tells us there is still a lot more we need to learn about how to deliver care at the end of life.”

The magazine also describes a new study by AARP that ranks the 50 states and the District of Columbia on the quality and accessibility of their long-term care supports and services. The ratings were determined by affordability and access; choice of setting and providers; quality of life and care; and support for family caregivers.

By those criteria, these regions are the top 10:

Minnesota
Washington
Oregon
Hawaii
Wisconsin
Iowa
Colorado
Maine
Kansas
Washington, D.C.

These states are the bottom 10:

Georgia
Louisiana
Florida
Tennessee
Kentucky
Indiana
Oklahoma
West Virginia
Alabama
Mississippi

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