Medicare Policies Result in Longer Nursing Home Hospice Stays

The length of the average Medicare certified hospice stay in a nursing home has doubled—from 46 days to 93 days—during the last 10 years, according to researchers at Brown University in Providence, RI.

Part of the reason for the increase is related to a standard daily payment rate for most Medicare hospice enrollment days is an incentive for some of the longer stays, according to the study, which evaluated hospice use in U.S. nursing homes between 1999 and 2006. It will appear in the August issue of The Journal of the American Geriatrics Society.

The study also found that the doubling of Medicare services in nursing homes is related to a 50% growth rate in the number of hospices—primarily for profit hospices. At the current time, a third of Medicare beneficiaries who die in nursing homes are accessing hospice services, and the study predicts that this number is expected to increase.

While the increased availability and use of Medicare sponsored hospice services was cited as a positive development by the researchers, concern was raised that stays were longest in states with the greatest provider growth. The researchers raised the possibility that reimbursement policies could be contributing to the volume of these very long stays.

"Although a direct link was found between increases in hospice enrollments and a rise in the number of providers, it is the increasingly long lengths of stay we believe that raise policy concerns." says Susan Miller, associate research professor of community health at Brown and lead author of the report.

However, she says caution should be placed against making sweeping changes to the program, which could deny nursing home residents hospice care. "What is needed is a tiered Medicare hospice payment system, which gives higher rates for the beginning and end of the patient's treatment," she says.

In addition to changing the rates of payment to reflect the timing of the more intense care needs, the researchers agree with a Medicare Payment Advisory Commission's recommendation that procedures for determining hospice eligibility recertification should be strengthened.

These changes would help the Medicare system avoid the possible scrutiny of nursing home residents who live beyond the physician certified six month prognosis—a Medicare requirement for hospice eligibility—and would permit patients to access the hospice care when they need it, Miller says. In 2006, 30% of nursing home hospice stays were found to be seven days or less. Currently, 500,000 U.S. adults die in nursing homes each year.

The Medicare hospice benefit is designed to provide visits by an interdisciplinary care team to better manage pain and other end of life issues and to provide psychosocial and spiritual support in the nursing home setting for residents and their families.