Average hospice length of stay is falling

Amid scrutiny from regulators and researchers about potential abuse of the Medicare hospice benefit, data released in January show that patient lengths of stay in hospice fell slightly in 2010.

The average length of stay in hospice care decreased to 67.4 days, down from 69.5 in 2008, according to data collected by the National Hospice and Palliative Care Organization, which represents about two-thirds of the nation's more than 5,000 for-profit and nonprofit hospices.

Though the average length-of-stay figure was drawn higher by the 12% of patients who remain in hospice longer than 180 days, half of patients spend 19.7 days or less in hospice. That figure also is down since 2008, when the median hospice stay was 21.3 days, said the report (link).

The figures cover hospice care delivered at patients' homes and in inpatient settings. The data do not reflect the first year of experience with a Medicare regulation that took effect in January 2011. The rule requires a physician or nurse practitioner to evaluate a hospice patient in a face-to-face meeting after 180 days and certify that the patient remains terminally ill and eligible for hospice care.

Medicare covers 84% of the patients in hospice, and the stricter standards are forcing organizations to make sure that the patients they care for belong in hospice, said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization.

"What this regulation is doing is raising awareness that the admission procedures of all hospices have to be within Medicare guidelines," he said. "Programs -- if over the long term they are going to be forced to answer questions about the patients being admitted -- are being incredibly more thoughtful and diligent about what those numbers are."

Hospice costs explode

Patients admitted to for-profit hospices typically stayed there longer, were likelier to remain in hospice for more than a year, and were more likely to have dementia and other noncancer diagnoses, said a Feb. 2, 2011, study in The Journal of the American Medical Association (link).

Some critics of commercial hospices say such facilities are more willing than nonprofits to admit patients with lower demands for skilled care and whose terminal prognosis is less certain, making it easier for these organizations to score profits on the flat daily rate the Medicare hospice benefit pays. Nearly 60% of hospices are for-profit, up from virtually none in the early 1980s. Medicare payments for hospice rose fourfold to $12 billion annually between 2000 and 2009, according to the Medicare Payment Advisory Commission. Four in 10 Americans who die each year do so under hospice care.

The new Medicare regulation, known as the face-to-face rule, applies to all hospices regardless of profit status. Schumacher said he has not seen much evidence to indicate that the standard is discouraging appropriate use of hospice, or that it is placing an undue burden on physicians.

"At the very beginning, there was concern about the amount of energy it would take to do this," he said. "But people are integrating this into their regular workflow."