Hospice: A True Value-Based Model

Added on Dec 1, 2014

The extension of Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys into the hospice space in 2015 will provide Medicare-certified hospices a gauge to measure how well they are meeting the needs of the patients and families they serve. 

The value of the Hospice CAHPS rollout goes beyond that, however. By recognizing specialized end-of-life care as a measurable experience along the health care spectrum, CMS is essentially inviting hospice to its rightful place at the health care table—a spot that has long been obscured by physicians’ aversion to discussing death and dying with their patients, according to Boston-based surgeon Dr. Atul Gawande

In his new book, Being Mortal: Medicine & What Matters in the End, Dr. Gawande bemoans the common notion that the goal of treatment should be to extend life at all costs. The  prevailing mindset within and outside of the health care community, he contends, has been that standard care is delivered when there’s hope, and hospice takes over when there’s none. In fact, hospice care is not about the absence of hope, it’s about having honest discussions about death with terminally ill patients and their families, finding out what matters most to them and using that insight to improve the quality of their last days, he explains.

“Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people,” Dr. Gawande writes. Through the “medicalization” of aging, “we have allowed our fates to be controlled by the imperatives of medicine, technology and strangers,” he says. “In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later." Hospice, on the other hand, "deploys nurses, doctors, chaplains, and social workers to help people with a fatal illness have the fullest possible lives right now.”

The difference, Dr. Gawande explains, comes down to priorities, and the degree to which clinician and patient priorities align. “People with serious illness have priorities besides simply prolonging their lives. If your problem is fixable, we know just what to do. But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity and extraordinary suffering.”

The answer does exist, and it can be found in hospice, which has as its goal to provide “a good life to the end,” based on what matters to patients and their families. This, along with efficacy research, makes hospice a promising model for improving the quality and value of end-of-life care in all settings.

In one recent study, for example, older oncology patients enrolled in hospice had significantly fewer hospitalizations, ICU stays and invasive procedures compared with those in other care settings during their last year of life. Not only was the hospice care less “medicalized,” the total costs were significantly lower with no survival disadvantage.

The idea that hospice gives patients what they need most in their final days is echoed in the findings of the Hospice CAHPS pilot study.The mean overall rating for the 29 Medicare-certified hospices participating in the trial was 93 out of 100, indicating that hospice providers are doing right by the families they serve.

As with all of the CAHPS instruments, the goal of Hospice CAHPS is to enable patients and families to make informed health care decisions based on quality and value and to promote accountability across providers. Through the use of advanced analytics, the results may also be used to identify and inform best practices for end-of-life care—independent of the setting in which it is delivered.