We have a unique opportunity right now to change the national conversation around end-of-life care and how we as a country can support that care. To achieve this, we need to change the premise of our conversations among families, friends and policymakers to discuss how we want to approach the end of our lives, in ways that maximize quality of life and time spent with loved ones.
For some time, it has been evident that the last year of a Medicare beneficiary’s life is too frequently full of wasteful spending that drives up health care costs and is contributing to the projected 2031 insolvency facing Medicare’s Hospital Trust Fund. This realization is given more urgency by data from the Centers for Medicare and Medicaid Services (CMS) showing that the average cost of a Medicare hospital stay has risen from $9,400 in 2000 to $15,500 in 2020, representing an increase of approximately 65 percent.
Advocates and researchers for years have noted that if more people chose to enter hospice care earlier in their end-of-life journey, not only would they and their families’ quality of life likely improve, Medicare would avoid paying for “wasteful care” — those costly medical interventions geared toward curing a disease that, sadly, often have little clinical benefit and end up adding to the stress and discomfort of many terminally ill beneficiaries.
It is true that hospice saves money. A recent study from NORC at the University of Chicago found in the last year of life, the total costs of care to Medicare for beneficiaries who used hospice was 3.1 percent lower than those who did not. In 2019, the last year data was not affected by the pandemic, Medicare spending for those who received hospice care was $3.5 billion less for hospice patients compared to those who received no hospice care. The research also showed that even when patients were in hospice for longer periods, of six months or more, cost savings to Medicare were achieved. Considering only 52 percent of Medicare’s 2019 decedents were enrolled in hospice, increased adoption of the practice would generate even more Medicare savings.
We know that care decisions are personal, emotional and typically much more nuanced and complex than economic analyses might suggest. What we really need to do is encourage conversations — with ourselves, with loved ones, within faith communities, with friends and neighbors, and with policymakers — about the ways in which we personally, and as a country, want to approach death. How can we focus on our personal and cultural values as we approach the end of life? How can we make sure that the end-of-life experience is about living that time to the fullest?
Starting in mid-February, former President Jimmy Carter has shown America one approach to end-of-life decisions by announcing he would forgo interventional, curative treatment in favor of hospice care, which is available to Medicare beneficiaries with a life expectancy of six months or less. The same NORC study that showed hospice saved Medicare billions of dollars also reaffirmed that hospice provides patients, families and caregivers increased satisfaction and quality of life, improved pain control, and reduced physical distress, grief, and other emotional pain. This is the discussion President Carter is showing us we need to have: How do we focus on maximizing the quality of life for the patient while supporting their physical, emotional and spiritual needs, as well as those of their family members and loved ones?
As leaders in hospice care, we believe framing end-of-life conversations this way has the potential to change the dynamics of the debate around Medicare spending in the last year of life by driving larger hospice-driven savings. While this approach to value-based, patient-centered care is reflective of the evolution most stakeholders want to see in health care, it represents the core of hospice’s approach since before it was approved as a Medicare benefit 40 years ago. By following President Carter’s leadership and re-framing these end-of-life conversations, America has the potential to support what the vast majority of us want: an end-of-life journey that is dignified, integrates our family and friends as desired, and keeps us as comfortable as possible.
Hospice does all these things, while simultaneously saving money — a rarity in our fragmented and interventionist health care system. As the Baby Boom generation begins to enter the phase of their lives when they will inevitably need more care and support at home, hospice is a program that must be protected, supported and strengthened.
William A. Dombi, Esq., is president and CEO of the National Association for Home Care & Hospice.
Ben Marcantonio is interim CEO of the National Hospice and Palliative Care Organization.