Elderly patients trying to exert some control over where they die still face formidable obstacles, recent research finds. Where they spend their final days may be determined as much by payment policies as by medical necessity or personal preference.
Most seniors would prefer to die at home or in the home of a loved one, but a new study of Medicare patients indicates only a third of them do.
The study, published Feb. 4 in The Journal of the American Medical Association, also shows that a smaller proportion of Medicare patients were dying in hospitals at the end of the last decade than at the beginning: 32.6 percent in 2000, versus 24.5 percent in 2009.
That's likely due both to increased availability of home hospice care and home care along with policies that discourage long hospital stays.
The research, based on the records of about 840,000 beneficiaries at least 66 years old who died in 2000, 2005 or 2009, indicates that hospice use at time of death nearly doubled, to 42.2 percent in 2009. That palliative care could have taken place at home, in a hospital, a nursing home or in a separate hospice facility. The National Hospice and Palliative Care Organization estimates about 41 percent of hospice deaths occur at a private residence.
The numbers also show that many seniors take a complex path to their deathbed. Nearly 30 percent of those who died in hospice were in that setting for three days or less. Of that group, 40 percent had been in a hospital ICU before they were transferred.
In 2000, a Medicare patient who died was moved an average of two times in the last 90 days of life; by 2009, that average increased to three times.
Dr. Joan Teno led the study. She has spent decades studying end-of-life care and is now a professor of health services policy and practice at Brown University in Providence, R.I.
For many patients, she said, hospice care is still just an "add on" to an aggressive pattern of care during the last days of life that many patients may not want and that results in little opportunity for patients or their families to prepare for death and grief.
Access to hospice may be further complicated by who pays for care in the $14 billion a year industry. Medicare payments cover about 85 percent, Medicaid supports another 5 percent, with the rest mainly covered through private insurance.
Basic Medicare rates range from $153 to $895 a day, depending on the level of service.
Medicare payments for hospice increased by more than 50 percent between 2005 and 2009, according to a report from the U.S. Department of Health and Human Services' inspector general's office.
The Medicare hospice benefit generally does not cover any services that are considered curative for the condition from which the patient is anticipated to die. It pays hospices fixed daily rates to care for each patient.
Almost since the government started paying for hospice in 1982, officials have expressed concern that hospices were taking in patients whose illnesses or prognosis did not qualify, turning end-of-life care into what amounted to long-term care that Medicare normally doesn't cover.
More recently, investigators found that 82 percent of hospice claims they examined for beneficiaries in nursing homes did not meet Medicare coverage requirements.
However, the journal Health Affairs reported in December that most hospices around the country have enrollment criteria that may limit patient access.
Based on a national survey of 591 hospices, researchers said 78 percent of these had at least one enrollment policy that could restrict access to care. Policies included not accepting patients who require chemotherapy or intravenous feeding, transfusions or palliative radiation treatments -- all of which can aid in comfort but also can be considered "curative."
Besides possibly running afoul of regulations, such treatments can increase costs for the hospice. The researchers, led by Melissa Carlson of the Mount Sinai School of Medicine in New York, suggested increasing the daily Medicare subsidy for patients needed more complicated care.