I’ll Have What She’s Having: Goldilocks and the Hospice Benefit

by: Eric Widera (@ewidera)

Two reports came out last week that can easily lead one to opposite conclusions about the current state of hospice care in the U.S.

The first was a Wall Street Journal (WSJ) report on how hospice care is being used too early in the course of a Medicare beneficiary’s illness. The article can pretty much be summarized by its subheading: “More dementia patients and others who die slowly are receiving care, causing costs to rise.”  NHPCO has a good response to the article, which I will not summarize here except by saying that my favorite line from it was : “People do not come with an expiration date, nor does their end-of life-care.”   While I agree with NHPCO’s response, I still found the WSJ article fascinating, in particular the finding that beneficiaries who were enrolled in hospice for more than 365 days accounted for about 32% of Medicare hospice payments. More striking is that those with very long lengths of hospice lengths of stay (on average 1000 days) accounted for a very small proportion of hospice patients (1%) yet resulted in 14% of Medicare’s hospice spending.

The second report that came out is from the Dartmouth Atlas Project and sponsored by the Hartford Foundation. Karl Steinberg wrote a post about the new report on Pallimed, which I will not rehash here. But I will say that I’m most struck with the report’s conclusion about hospice care in the US: “the data in this report suggest that we are still waiting too long to refer patients to hospice care.” More specifically, they found that 16.8% of Medicare decedents were enrolled in hospice care within three days of their deaths, a number that varied more than fourfold across hospital referral regions.

So, which is it? To soon? Too Late?

In the fairy tail Goldilocks and the Three Bears, Goldilocks found the porridge that was right for her, something that was not too hot and not too cold, but just right.  It may seem reasonable then to want the same thing that Goldilocks deemed optimal.  But really, who cares what Goldilocks thinks?    It was never her damn porridge to start with.  The chairs, the bed, and the porridge were all designed for the needs of someone else. And look what happened to her.  She ended up jumping from a window and is never heard or seen of again.

No, what we really need is to say good riddance to Goldilocks and think long and hard about who should really be deciding what is just right.