What do short and long hospice stays tell us about Medicare policy? Donald H. Taylor, Jr. Sanford School of Public Policy Duke University

Some work funded by 2 grants HCFO Initiative of RWJ: Identifying the Use, Cost and Quality Tradeoff in the Medicare Hospice Benefit AHRQ 1RO1 HS018360: Priorities for Medicare Advanced Cancer Coverage Sponsors are not responsible for the presentation/my conclusions

Cordt Kassner, Hospice Analytics helped with slides & some of the empirical work I discuss. Policy conclusions/suggestions are my responsibility

2012 Medicare Hospice Percentage of Discharged Deceased x LOS Of those discharged deceased from hospice: - 25% die in 4 days or less - 50% die in 13 days or less - 75% die in 43 days or less www.HospiceAnalytics.com 6

2012 Medicare Hospice Percentage of Discharged Alive x LOS Of those discharged alive from hospice: - 25% are discharged by day 17 - 50% are discharged by day 57 - 75% are discharged by day 127 www.HospiceAnalytics.com 8

Short Stay Concerns Quality Foregone cost savings Persistent: 1 in 4 dying 4-5 day LOS ~10 yrs Problem or preference? How can we lengthen short stays? Worry: will changes exacerbate short stay

Long Stay Concerns More likely to be discharged alive Fraudulent Inappropriate Back door LTC benefit? Increase cost at longer length of use

Hospice Saves Medicare $ even w/long stays in N. C Hospice Saves Medicare $ even w/long stays in N.C. (preliminary; static use)

Conclusions/What Next? More focused audit Hospice policy change inevitable. What is the goal? With appropriate comparison, hospice saves Medicare money even with long stays Could save more (worry unintended conseq) Some long stay hospice back door LTC What do patients want?

Final Thoughts The hospice benefit in Medicare has been expected to improve quality & save money since the beginning A very rare standard in health care Hospice shouldn’t be the only part of Medicare subjected to such questions