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University researchers recently found that a Medicare policy that prevents patients from being reimbursed for simultaneous skilled nursing care and hospice results in unwanted aggressive treatments and hospitalizations at the end of life. The policy prompts patients to choose skilled nursing over hospice because of its lower cost, compromising their quality of care, according to the study. The study, published Oct. 30 in the Journal of the American Geriatrics Society, focused specifically on care given to patients with advanced dementia.

Professor of Health Services Policy Susan Miller, lead author of the study, said she has frequently encountered this problem in hospice facilities during her 15 years studying end of life care at Brown. With this study, she "wanted to quantify the effect of the Medicare policy" on patients' quality of care, she said. She has also always been interested in dementia so these two factors directed the focus of the study. 

The researchers collected the records of 4,344 nursing home residents with advanced dementia receiving skilled nursing care who passed away in 2006. Of this sample, 1,086 patients received hospice care in addition to skilled nursing care. 

Patients' access to hospice greatly affects the kind of care they receive, the study found. But since choosing hospice means giving up skilled nursing care and thus paying for the entire cost of nursing home stays, many families select skilled nursing over hospice. Medicare pays for room and board for skilled nursing care, but the hospice benefit does not.

The study found that patients who received hospice either during or after skilled nursing care were far less likely to die in a hospital than people who did not receive hospice. Patients who received hospice also received fewer feeding tubes, IV fluids and occupational or physical therapy. 

Miller said she expected to find the result of fewer hospitalizations and less aggressive treatments for patients receiving hospice care, but she was surprised by the study's finding about persistent pain - the study found that patients who received hospice after stays in skilled nursing facilities were just as likely to experience persistent pain as patients without hospice. But patients that received simultaneous skilled nursing care and hospice were 65 percent more likely to experience pain. Miller acknowledged that this result in part could be "an artifact of our experimental design." 

Susan Allen, professor of health services, policy and practice, said the study is "really well done scientifically." Allen credited the authors' extensive amount of experience in this subject area.

Allen was most interested to learn that people who receive skilled care still greatly benefit from hospice. This research "adds to a body of knowledge on the benefits of hospice care," she said.

The federal government will investigate this issue under the Medicare Hospice Concurrent Care demonstration project, according to a University press release. Whether the results of this study will influence Medicare policy is unclear, Miller and Allen said. 

"It takes a lot to change policy," Allen said. It requires a "substantial body of evidence, you need more than one study to prove cost savings." 

 Miller added that "the government may be hesitant to address this issue due to the cost of simultaneous treatments." 

"If insurance companies find that it does reduce costs, it could be changed, but if costs are higher then probably not," he said. 

"Everybody knows somebody with dementia - it's very important for people to be advocates," Miller said.

Miller stressed the importance of family involvement in their relatives' care to avoid burdening them with unnecessary treatments. 


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