Medicare kidney failure patients enter hospice too late to reap full benefits

As they approach the end of their lives, many patients with end-stage renal disease face a harrowing choice: continue dialysis treatment or enter hospice care. Under current policy, Medicare will not simultaneously pay for dialysis and hospice care for patients with a terminal diagnosis of renal failure. This usually means that in order to receive hospice care, patients must first stop dialysis treatments. A new study by researchers at Brigham and Women's Hospital found that, nationally, only 20 percent of Medicare patients with end-stage renal disease who died used hospice, and those who did were almost twice as likely to have very short hospice stays (i.e., three days or less) compared to patients with other advanced chronic illnesses. Health care utilization and costs for these patients with very short hospice stays were similar to or higher than those for patients who had not been referred to hospice. The study's results are published in JAMA Internal Medicine.

"Since most patients die within a week of terminating dialysis, this Medicare requirement effectively bars hospice entry until the final days of life for many of these patients," said lead author Melissa Wachterman, MD, MSc, MPH, physician at BWH.

Hospice, covered by Medicare, Medicaid and most private insurers, is a benefit available to persons with a life expectancy of six months or less. Hospice has been associated with enhanced patient and family quality of life and satisfaction with care, improved bereavement outcomes, and reduced medical costs as compared to usual care. Nationally, almost 50 percent of people on Medicare who died received hospice care with a median length of stay of 23 days and an average of 70 days.

Wachterman et al.'s study found that approximately 42 percent of dialysis patients who used hospice were enrolled for three days or less. "These short hospice stays make it very difficult for patients dying of kidney disease and their families to fully benefit from the expertise in pain and symptom management that hospice can offer and the emotional support that hospice can provide," said Wachterman.

Though less likely to die in the hospital, costs for dialysis patients with very short hospice stays were similar to those not receiving hospice care. Longer lengths of stay in hospice beyond three days, on the other hand, were associated with progressively lower rates of health care utilization and costs.

Wachterman adds that in addition to the benefits that more timely hospice referral affords dialysis patients and their families, longer time in hospice care may also translate into meaningful reductions in costs near the end of life, thus achieving a triple aim of health care: improved patient experience of care (including quality and satisfaction); improved health of populations; and reduced per capita healthcare costs.

"We hope our work will spark discussions about potential changes to Medicare policy to better serve the needs of the ever-growing population with end-stage renal disease approaching the end of life," said Wachterman. "We believe that improving access to palliative care services for these patients will be pivotal in supporting the delivery of goal-concordant care and smoothing transitions to hospice as patients approach the end of life."