• Melissa D Aldridge, Andrew J Epstein, Abraham A Brody, Eric J Lee, R Sean Morrison, and Elizabeth H Bradley.
• 1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.
• J Palliat Med. 2018 Jan 1; 21 (1): 55-61.

BackgroundCare at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice.ObjectiveTo determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees.DesignLongitudinal, observational cohort study (2008-2010).Setting/SubjectsMedicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355).MeasurementsWe used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures.ResultsHospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices.ConclusionsPatients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

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