Perceptions of hospice have undergone a pervasive and remarkable change in the last few decades. Twenty years ago, the word would almost invariably prompt backlash from patients and their families, who felt that their doctors were giving up on their care. It was a negative experience both for the patients who had to come to terms with their conditions, and for the doctors, who had to shoulder the emotional burden of such discussions regularly. 

Yet, because hospice was framed in such a negative light, care providers often strived to lengthen their patients’ lives by whatever means possible, even if that meant overtreating or continuing to take curative measures when it was clear that the time for them was past. This approach often meant that their patients spent of their remaining time in stressful hospital environments undergoing uncomfortable tests and treatments for the sake of longevity. Prioritizing the comfort of hospice was seen as a defeat, even though it was never meant to be one. 

Hospice is designed to provide a patient-centered model of care within home-like environments that focuses on relieving suffering and improving patient experiences during their final days. In one study published in BMJ’s Supportive and Palliative Care, researchers found that those who enroll in hospice programs during their last six months of life tended to have better pain control, express more satisfaction with treatment, spend fewer days in the hospital, and have lower rates of hospital and intensive care mortality than those who choose not to enroll. 

The benefits of such end-of-life care are clear — and in recent years, they have served as the impetus for a widespread hospice-positive movement. According to statistics put forth by Excel Health, hospice utilization increased by 6.5% between 2016 and 2017, with 1.3 million Medicare enrollees reported in the latter year. A full 48.2% of Medicare beneficiaries who passed away in 2017 were receiving hospice services at their time of death. 

Today, hospitals across the country have teams dedicated to improving physicians’ and families’ perceptions of hospice. A great deal of work has been done to recast the culture surrounding hospice in a more positive light, and to encourage patients to enroll in end-of-life care services early. 

Creating a More Sensitive and Effective Hospice Experience

As provider and patient perceptions of hospice have evolved, more medical teams are realizing that the best approaches to end-of-life care are not centered around prognosis and treatment, but receptive listening and support. In most cases, these approaches involve facilitating sensitive conversations with patients outside of strictly medical consultations. 

For example, one 2018 study from Stanford found that patients who participated in conversations with nonmedical lay health workers were significantly more likely to have their end-of-life preferences documented in their electronic health records within six months of first outreach. The enrollment gap is remarkable: those who had the conversations experienced 92% enrollment, as opposed to 18% for the control group. The benefit of having these conversations is clear, as is the study’s conclusion that the increase in hospice adoption can be facilitated without increasing the burden of responsibility doctors face. 

To quote Manali Patel, an assistant professor of medicine at Stanford and the lead author for the study above, “A goals-of-care conversation is not about prognosis. It’s a holistic approach to understanding the patient’s wishes and how they want to experience their life. You don’t need higher-level training to have that conversation. You just need a very supportive ear.”

In designing hospice programs to prioritize nonmedical conversations, provider organizations can boost hospice enrollment, improve doctors’ understandings of patient preferences, and lay the groundwork for better care. 

Facilitating Significant Cost Benefits

Hospice offers significant potential for widespread cost savings. As of 2013, data provided by Medicare suggests that roughly 5% of Americans accounted for 50% of the nation’s healthcare spending, with the majority of those costs accrued during a patient’s final year of life. 

However, research has demonstrated that hospice services can significantly defray the cost of end-of-life care. One 2018 study of FFS Medicare-eligible seniors with malignancies under active treatment found that non-hospice patients had, on average, 25% higher medical costs than hospice-enrolled participants during the last six months of life. 

The numbers become even more striking when one considers the impact that the above-mentioned conversational strategies can have on cost savings. Stanford’s lay worker study found that those who communicated with lay health workers were six times less likely to be hospitalized or seen in the emergency department than their counterparts in the control group, and were twice as likely to utilize hospice services. The median health care cost within 30 days of death was $1,048 for those who spoke with lay workers, compared with $23,482 for those who did not. 

Moreover, while the cost-savings hospice allows are significant, they are not the only benefit that those who receive end-of-life services receive. Hospice can be enormously beneficial for patients and their families. Multiple studies have demonstrated that hospice can be tremendously helpful for patients and their families, as well. Researchers for one UK-based qualitative study conducted interviews with bereaved carers and found that, in general, family members reported very positive experiences with hospice care. Those interviewed particularly highlighted the benefits of having high-quality and consistent care, as well as the value of being able to discuss medical problems and help their loved ones access complementarity therapies as needed. 

Another study conducted in 2005 also found that certain specific hospice services — in this case, hospice daycare — could not only provide family carers with a needed respite but also facilitate a venue for patients to socialize with others in hospice. Researchers reported that participation in day services led to a notable increase in a patient’s sense of self-worth, independence, and confidence. Even without the clear cost-savings hospice creates, these benefits to the end-of-life experience cast such services as an invaluable necessity for patients and their families alike. 

In an era where health care costs are painfully high, expanding and taking a more nuanced, sensitive approach to hospice is a clear must for hospice providers. Care organizations have begun to do so, but providers need to facilitate more patient outreach and pre-enrollment conversations for the sake of improving care in future years. 

Where Hospice May Go from Here

Medicare’s commitment in hospice care is experiencing a steady upward trend. Even amidst budget cuts, hospice care stood as one of the few fields that experienced an uptick in investment. In 2017, Medicare spent nearly $19 billion on hospice care, a 6.3% increase from the year before. 

More Medicare-covered patients are receiving hospice services than ever before and, often, stay in their programs for longer. Currently, the median length of stay for hospice stands at around 17 days, though researchers report that patients receive peak benefits from hospice programs when they receive services for a month or longer. However, this isn’t to say that people should be in hospice for months on end. Much of the overspending that occurs in hospice stems from patients who are incorrectly referred to hospice when they should be enrolled in a longer-term, less expensive program. 

However, there are ways that care organizations can cut back on the number of patients who are incorrectly — and with a great deal of unnecessary expense — referred to hospice care. 

Recently, the Center for Medicare & Medicaid Innovation (CMMI) announced that it would be expanding its Medicare Advantage Value-Based Insurance Design (VBID) model to allow hospice carve-in by 2021. Hospice care is not currently approved as a covered benefit on Medicare Advantage plans; however, the change could empower care organization to provide better-quality and more cost-effective value-based care. 

Currently, physicians who ascribe to a value-based model can shoulder the cost risk for patient care; this gives providers a strong incentive to keeping those they treat healthy and hospital spending low. However, with the way matters currently stand, once a Medicare patient is diagnosed and referred to hospice, the federal government is obliged to remove them from the provider’s risk pool — and away from the low-cost, high-quality imperative of the value-based, risk-sharing model. This change opens patients to the above-mentioned potential problems of too-long hospice stays and overspending. 

With the new CMMI announcement, however, it may be possible to keep Medicare Advantage patients within their usual risk pool even when they need hospice care. Providers would then be able to ensure that the patients receive top-notch hospice care at a high quality and for the correct amount of time. 

Perceptions of hospice services have changed for the better over the decades, leading to an increase in enrollment that has both improved patient care and limited out-of-pocket care costs. Moreover, the benefits provided by hospice will likely grow as Medicare Advantage programs increasingly adopt value-based structures in their models.