Effect of Hospice Use on Costs of Care for Long-Stay Nursing Home Decedents

Abstract

OBJECTIVES: To analyze the costs for long-stay (>90 days) nursing home (NH) decedents with and without hospice care. DESIGN: Retrospective cohort study using a 1999-2009 data set of linked Medicare and Medicaid claims and minimum data set (MDS) assessments. SETTING: Indiana NHs. PARTICIPANTS: Long-stay NH decedents (N = 2,510). MEASUREMENTS: Medicare costs were calculated for 2, 7, 14, 30, 90, and 180 days before death; Medicaid costs were calculated for dual-eligible beneficiaries. Total costs and costs for hospice, NH, and inpatient care are reported. RESULTS: Of 2,510 long-stay NH decedents, 35% received hospice. Mean length of hospice was 103 days (median 34 days). Hospice users were more likely to have cancer (P < .001), a do-not-resuscitate order in place (P < .001), greater cognitive impairment (P < .001), and worse activity of daily living (ADL) function (P < .001) and less likely to have had a hospitalization in the year before death (P < .001). In propensity score analyses, hospice users had lower total Medicare costs for all time periods up to and including 90 days before death. For dually eligible beneficiaries, overall costs and Medicare costs were significantly lower for hospice users up to 30 days before death. Medicaid costs were not different between the groups except for the 2-day time period. CONCLUSION: In this analysis of costs to Medicare and Medicaid for long-stay NH decedents, use of hospice did not increase costs in the last 6 months of life. Evidence supporting cost savings is sensitive to analyses that vary the time period before death.