GAO

United States General Accounting Office

Report to Congressional Requesters

September 2000 MEDICARE

More Beneficiaries

Use Hospice but for

Fewer Days of Care

GAO/HEHS-00-182

Page 1 GAO/HEHS-00-182 Medicare Hospice Benefit

Contents

Letter 3

Appendixes Appendix I: Methodology for Developing Information on Medicare

Hospice Use and Hospice Providers 32

Appendix II: Patterns and Trends in Hospice Supply and Use 35

Appendix III: Comments From the Health Care Financing

Administration 49

Tables Table 1: Medicare Hospice Use Rates in Selected States and the

District of Columbia, 1998 10

Table 2: New Hospice Enrollees by Primary Diagnosis, 1992 and

1998 11

Table 3: Hospice Use Rates for Selected Diagnoses, 1992 and 1997 12

Table 4: Hospice Benefit Use by Weekly Intervals, 1992 and 1998 14

Table 5: Growth in Medicare Hospice Programs by Provider

Characteristics, 1992 and 1999 27

Table 6: Growth in Number and Size of Hospices in States With Large

Medicare Populations, 1992 and 1998 28

Table 7: Number of Hospice Providers by Control, Affiliation, Size,

and Location, 1992-99 35

Table 8: Percentage of Hospice Providers by Control, Affiliation, Size,

and Location, 1992-99 36

Table 9: Average Number of Days Beneficiaries Used Hospice by

Provider Control, Affiliation, Size, and Location, 1992-98 37

Table 10: Use of Medicare Hospice Benefits by Cancer and Noncancer

Patients, 1992-98 38

Table 11: Number of Hospice Users by Selected Common

Diagnoses, 1992-98 39

Table 12: Percentage of Hospice Users by Selected Common

Diagnoses, 1992-98 40

Table 13: Average Number of Days Beneficiaries Used Hospice by

Selected Common Diagnoses, 1992-98 41

Table 14: Hospice Use and Supply by State, 1992 and 1998 42

Table 15: Percentage Change in Hospice Use and Supply by State,

1992-98 44

Table 16: Change in Percentage of Providers, Users, and Days of

Care by Provider Type, 1992-98 46

Table 17: Variation in Hospice Use Among Medicare Decedents by

State, 1998 47
Contents

Page 2 GAO/HEHS-00-182 Medicare Hospice Benefit

Figures Figure 1: Number of Medicare Hospice Benefit Users, 1992-98 8

Figure 2: Decline in Average and Median Hospice Lengths of

Service, 1992-98 13

Figure 3: Average Days of Use for Cancer and Noncancer Patients,

1992-98 15

Figure 4: Decline in Average and Median Days of Hospice Care for

Cancer and Noncancer Patients, 1992-98 21

Figure 5: Growth in the Number of Medicare Hospices and New

Entrants, 1992-99 25

Abbreviations

BBA Balanced Budget Act of 1997

CDC Centers for Disease Control and Prevention

CON certificate of need

HCFA Health Care Financing Administration

HHA home health agency

HHS Department of Health and Human Services

HMO health maintenance organization

IOM Institute of Medicine

MSA metropolitan statistical area

OIG Office of Inspector General

SNF skilled nursing facility
Page 3 GAO/HEHS-00-182 Medicare Hospice Benefit

United States General Accounting Office

Washington, D.C. 20548

Health, Education,

and Human Services Division

B-284476 Letr

September 18, 2000

The Honorable Charles E. Grassley

Chairman, Special Committee on Aging

United States Senate

The Honorable John B. Breaux

Ranking Minority Member, Special Committee on Aging

United States Senate

The Honorable Ron Wyden

United States Senate

The Medicare hospice benefit was designed to serve terminally ill persons

who choose not to continue medical treatment to cure or extend life but

instead to receive services focused on comfort and pain relief as well as

emotional and spiritual support. Although hospice services are available in

inpatient settings, most services are provided in the patient’s home or

residence. The hospice benefit is available to beneficiaries with a prognosis

that they have 6 months or less to live, but hospice users may receive

services for longer than 6 months, provided that they are periodically

recertified as eligible.

Some patient advocates, hospice providers, and others contend that certain

Medicare beneficiaries for whom hospice care is appropriate may have

difficulty in gaining access to hospice care or receiving services in a timely

manner. However, officials of the Health Care Financing Administration

(HCFA) and others assert that the benefit is basically working as intended

and meeting the needs of those who choose to use it. You asked us to

examine (1) the patterns and trends in hospice use by Medicare

beneficiaries, (2) factors that affect the use of the hospice benefit, and (3)

the availability of hospice providers to serve the needs of Medicare

beneficiaries.

To address these issues, we analyzed HCFA claims and enrollment and

provider data for a 9-year period ending in December 1999.1 (A detailed

description of our methodology is in app. I.) In addition, we interviewed

1

Data were not available before 1991.
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officials of hospice programs representing various affiliations, enrollment

sizes, and locations; officials responsible for processing Medicare hospice

claims; HCFA officials; patient advocacy groups; experts in palliative

medicine; and trade association representatives. We also reviewed relevant

research as well as Medicare program regulations, manuals, and guidance.

We performed this review from November 1999 through August 2000 in

accordance with generally accepted government auditing standards.

Results in Brief The number of Medicare beneficiaries choosing hospice services has

increased substantially. In 1998, nearly 360,000 Medicare beneficiaries

enrolled in a hospice program, more than twice the number who elected

hospice in 1992. Of Medicare beneficiaries who died in 1998, about one in

five used the hospice benefit, but use varies considerably across the states.

Although cancer patients account for more than half of Medicare hospice

patients, growth in use has been particularly strong among individuals with

other common diagnoses such as heart disease, lung disease, stroke, and

Alzheimer’s disease. Although more beneficiaries are choosing hospice,

many are doing so closer to the time of death. The average period of

hospice use declined from 74 days in 1992 to 59 days in 1998. Half of

Medicare hospice users now receive care for 19 or fewer days, and care for

1 week or less is common.

Many factors influence the use of the Medicare hospice benefit. Decisions

about whether and when to use hospice depend on physician preferences

and practices, patient choice and circumstances, and public and

professional awareness of the benefit. Along with these factors, increases

in federal scrutiny of compliance with program eligibility requirements may

have contributed to a decline in the average number of days of hospice care

that beneficiaries use.

The growth in the number of Medicare hospice providers in both urban and

rural areas and in almost every state suggests that hospice services are

more widely available to program beneficiaries than in the past. Between

1992 and 1999, the number of hospices participating in Medicare increased

82 percent, with large providers and those in the for-profit sector

accounting for a greater proportion of the services delivered. At the same

time, hospice industry officials report cost pressures from declining patient

enrollment periods and increased use of more expensive forms of palliative

care, such as radiation and chemotherapy for pain relief. Because reliable

data on provider costs are not available, however, the effect of these

reported cost pressures on the overall financial condition of hospice
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providers is uncertain. As required by the Balanced Budget Act of 1997

(BBA), HCFA began collecting information in 1999 from hospice providers

about their costs to allow a reevaluation of the Medicare hospice payment

rate.

Background The Medicare hospice benefit, authorized in 1982 under part A of the

Medicare program, covers medical and palliative care services for

terminally ill beneficiaries. A Medicare-certified hospice provides physician

services, nursing care, physical and occupational therapy, home health aide

services, medical supplies and equipment, and short-term inpatient hospital

care for pain control and symptom management. In addition, the hospice

benefit provides coverage for several services not generally available under

the regular fee-for-service Medicare benefit. These include outpatient

prescription drugs for treating pain and other symptoms of the terminal

illness, homemaker services, short-term inpatient respite care, and

bereavement counseling for the patient’s family.2

Patients may receive services from freestanding hospice providers or from

a hospice program based in a home health agency, hospital, or skilled

nursing facility. For each day a beneficiary is enrolled, the hospice provider

is paid an all-inclusive, prospectively determined rate, depending on the

level of hospice care provided (routine home care, continuous home care,

inpatient respite, or general inpatient care).3 Initial payment rates were

based on cost data reported by 26 hospice programs that participated in

Medicare’s hospice demonstration project from 1980 to 1982.4 Since 1993,

these rates have been updated by an annual statutory adjustment factor

2

Outpatient medications and respite care are subject to limited coinsurance by beneficiaries.

Beneficiaries pay 5 percent of the cost of drugs or $5 per prescription, whichever is less, and

they pay 5 percent of hospice payments for respite care but no more than the Medicare

hospital deductible, which is $776 for calendar year 2000.

3

For routine home care, the hospice is paid a daily rate for each day a beneficiary is enrolled,

regardless of whether or not services are provided each day. Routine home care is the

default payment rate when other levels of care are not provided. In 1998, 97 percent of

hospice care days were paid at the routine home care rate.

4

Cost data included the kinds of services furnished, their costs, and the frequency of their

provision.
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Page 6 GAO/HEHS-00-182 Medicare Hospice Benefit

tied to inflation in the hospital market basket (a measure of the cost of

goods and services purchased by hospitals nationwide).5

Eligibility for hospice services requires that the beneficiary’s physician and

the hospice medical director (or other physician affiliated with the

hospice) certify that the individual’s prognosis is for a life expectancy of 6

months or less, if the terminal illness runs its normal course. Beneficiaries

who elect hospice must waive all other Medicare coverage of care related

to their terminal illness, although they retain coverage for services

unrelated to their terminal illness. A beneficiary can cancel his or her

election of hospice benefits at any time and return to regular Medicare, and

beneficiaries are free to reselect hospice coverage at a later date. While

there are currently no limits on the number of days an individual can

receive hospice care, a beneficiary’s prognosis must be reaffirmed at 90

days, at 180 days, and every 60 days thereafter.6

The hospice eligibility requirement that a beneficiary be certified as having

a prognosis of 6 months or less has been an ongoing concern expressed by

advocates and providers. The requirement has been challenged as difficult

to implement and a deterrent to hospice referrals, especially for

beneficiaries with noncancer diagnoses. Research suggests that it can be

difficult for physicians to accurately predict whether a patient is likely to

die within 6 months.7 It is particularly difficult to estimate life expectancy

for persons with noncancer diagnoses because the course of their disease

5

The daily base payment rates for fiscal year 2000 are $98.96 for routine home care, $577.59

for continuous home care, $102.37 for inpatient respite care, and $440.22 for inpatient

hospital care. These base rates are adjusted by the hospital wage index to reflect differences

in wage levels in different areas of the country.

6

Before 1990, Medicare payments to hospices were limited to a 210-day lifetime maximum

per patient. From 1990 to 1997, coverage was limited to a lifetime maximum of four benefit

periods but an unlimited number of days.

7

A recent study found that physicians are inaccurate in their predictions of how long their

terminally ill patients have to live. See N. Christakis and E. Lamont, “Extent and

Determinants of Error in Doctors’ Prognoses in Terminally Ill Patients: Prospective Cohort

Study,” British Medical Journal, Vol. 320 (Feb. 19, 2000), pp. 469-73.
B-284476

Page 7 GAO/HEHS-00-182 Medicare Hospice Benefit

is likely to be erratic.8 For example, patients with heart disease are more

likely to die suddenly than persons with cancer, who commonly have a

period of steady decline before death. Similarly, very elderly people in frail

health or with certain chronic illnesses may experience long periods of

declining health punctuated by several medical crises—any one of which

can be fatal. In such cases, physicians may find it difficult to justify a

hospice referral for beneficiaries who appear to be relatively stable, and, as

a result, the physicians may delay initiation of hospice services until a

medical crisis occurs shortly before death.

The Number of

Beneficiaries Using

Hospice Has Grown as

Average Days Used

Have Declined

From 1992 to 1998, the number of Medicare beneficiaries enrolling in

hospice more than doubled, with growth in all population subgroups and in

all states. Growth was particularly rapid among beneficiaries with

diagnoses other than cancer. At the same time, many beneficiaries had

shorter stays. On average, the days of hospice service used per beneficiary

declined by about one-fifth during the 7-year period and beneficiaries with

diagnoses other than cancer experienced the sharpest reductions.

The Number of Medicare

Hospice Users More Than

Doubled in 7 Years

Our analysis of Medicare claims data indicates substantial growth in

hospice use. The number of beneficiaries electing hospice care increased 2

1⁄2 times from 1992 to 1998, from about 143,000 to nearly 360,000 persons

annually. (See fig. 1.) Across most demographic groups, the use of hospice

services has grown at a relatively consistent rate. Thus, hospice users today

are similar to users in 1992; the distribution of enrollees by race has not

changed (89 percent are white), and the proportion of enrollees who are

women has climbed only slightly (from 50 to 54 percent). However, the use

of hospice services grew more rapidly among beneficiaries aged 80 and

older than it did among younger beneficiaries. This age group now makes

up 47 percent of Medicare hospice enrollees, up from 35 percent in 1992.

8

Researchers have found that for seriously ill hospitalized patients with advanced chronic

obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, it was

not possible to accurately identify in advance those who would die within 6 months. For

example, the most inclusive criteria excluded 58 percent of patients who died within 6

months of discharge, while 70 percent of patients identified as likely to die within 6 months

survived longer. In contrast, the most restrictive criteria eliminated 99 percent of patients

who died within 6 months but 53 percent of patients identified as likely to die within 6

months survived longer. See E. Fox and others, “Evaluation of Prognostic Criteria for

Determining Hospice Eligibility in Patients With Advanced Lung, Heart, or Liver Disease,”

Journal of the American Medical Association, Vol. 282, No. 17 (Nov. 4, 1999), pp. 1638-45.
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Page 8 GAO/HEHS-00-182 Medicare Hospice Benefit

Figure 1: Number of Medicare Hospice Benefit Users, 1992-98

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

0

50

100

150

200

250

300

350

400

1992 1993 1994 1995 1996 1997 1998

Number in Thousands

143.1

180.1

223.0

258.5

294.9

325.3

358.9
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Overall, 19 percent of Medicare beneficiaries who died in 1998 received

hospice services, compared with 8 percent in 1992.9 However, this measure

understates the proportion of Medicare beneficiaries who choose hospice

care among those for whom the benefit was intended. According to a

former president of the National Hospice Organization, “when the number

of deaths nationwide is adjusted to reflect only those that are likely to be

appropriate for hospice care, the percentage of dying patients cared for in

hospice care is probably about 40 percent.”10

Some groups of beneficiaries are more likely to choose hospice services

than others. For example, 20 percent of white Medicare beneficiaries who

died in 1998 elected hospice services, compared with 15 percent of black

beneficiaries who died that year. Similarly, the use of hospice services is

more common among beneficiaries who are enrolled in Medicare health

maintenance organizations (HMO) at the end of life than among those in

fee-for-service plans. Of the beneficiaries who died in 1998, 27 percent of

those enrolled in an HMO elected hospice, compared with 18 percent of

fee-for-service beneficiaries.11 (See app. II for detailed information about

hospice use rates among decedents.)

In addition, the proportion of Medicare decedents who used the hospice

benefit varies widely by state. For example, in 1998, the number of hospice

users as a share of Medicare decedents was more than four times higher in

Arizona than in Maine. Table 1 shows states with the highest and lowest

rates of hospice use in 1998.

9

A recent study found that about 18 percent of Medicare beneficiaries who died in 1996 used

hospice services. See Department of Health and Human Services, Assistant Secretary for

Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy, Medicare’s

Hospice Benefit: Use and Expenditures, 1996 Cohort (Mar. 2000).

10John J. Mahoney, “The Medicare Hospice Benefit—15 years of Success,” Journal of

Palliative Medicine, Vol. 1, No. 2 (1998), pp. 139-46.

11We classified Medicare beneficiaries as enrolled in an HMO or fee-for-service care at the

end of life on the basis of their status in the month they died. When an HMO enrollee elects

hospice, the monthly HMO payment is reduced, and the HMO then bills Medicare on a feefor-service basis for any covered medical services unrelated to the terminal illness.
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Page 10 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 1: Medicare Hospice Use Rates in Selected States and the District of

Columbia, 1998

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and Medicare

decedent data from the denominator file, an abbreviated version of HCFA’s Medicare enrollment

database.

The Growth in Hospice Use

Is Strongest Among

Beneficiaries With

Noncancer Diagnoses

Although people who die from cancer are more likely to choose hospice

services than are those who die from other conditions, the use of hospice

services by beneficiaries with noncancer diagnoses has increased rapidly.

From 1992 to 1998, hospice enrollment by beneficiaries with cancer

increased 91 percent, while enrollment by beneficiaries with all other

conditions increased 338 percent. The most dramatic growth in use was

among individuals with other terminal conditions, such as heart disease,

lung disease, stroke, or Alzheimer’s disease. About 43 percent of

beneficiaries who elected hospice in 1998 had noncancer diagnoses,

compared with about 24 percent in 1992. Table 2 shows the distribution of

new hospice enrollees by primary diagnosis.

State

Hospice users as a percent

of Medicare decedents

U.S. total 19%

Highest use

Arizona 36

Colorado 30

Florida 29

Oregon 26

New Mexico 25

Nevada 24

Lowest use

Alaska 6

Maine 8

South Dakota 11

Tennessee 11

Wyoming 11

Washington, D.C. 12
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Table 2: New Hospice Enrollees by Primary Diagnosis, 1992 and 1998

a

Patients entering hospice may have more than one medical condition or diagnosis. Data include only

the first, or principal, diagnosis listed for each patient.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

For many of the leading causes of death, the proportion of elderly

decedents who use the hospice benefit has increased. In 1997, about half of

the people aged 65 and older who died from cancer had used hospice

services, compared with about one-fourth in 1992.12 This pattern generally

held for breast cancer, lung cancer, and prostate cancer. However, the use

of hospice services is even more common among persons with other types

of cancer; roughly 75 percent of people age 65 and older who died from

brain or liver cancer in 1997 used hospice services before death. The

proportion of elderly decedents who used hospice services also increased

among beneficiaries who died from other causes. Table 3 shows the change

in hospice use rates from 1992 to 1997 for common hospice diagnoses.

Primary diagnosisa

1992 1998

Number Percent Number Percent

All cancer 108,232 75.6 206,190 57.4

Lung 29,966 20.9 57,841 16.1

Prostate 10,052 7.0 15,494 4.3

Breast 7,602 5.3 13,093 3.6

Colon 6,697 4.7 13,278 3.7

Pancreatic 6,359 4.4 12,116 3.4

Other 47,556 33.2 94,368 26.3

All noncancer 34,878 24.4 152,759 42.6

Congestive heart failure 6,141 4.3 24,248 6.8

Chronic obstructive pulmonary disease 4,112 2.9 15,765 4.4

Stroke 2,140 1.5 13,282 3.7

Alzheimer’s disease 1,591 1.1 11,836 3.3

“Ill-defined conditions” 888 0.6 7,599 2.1

Other 20,006 14.0 80,029 22.3

Total 143,110 100.0 358,949 100.0

12A recent study found that 51 percent of all 1998 Medicare cancer decedents used hospice

care. See Medicare Payment Advisory Commission, Medicare Beneficiaries Costs and Use of

Care in the Last Year of Life (May 2000).
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Table 3: Hospice Use Rates for Selected Diagnoses, 1992 and 1997

a

The denominator used for calculating noncancer use rates includes people who died unexpectedly

(for example, from a first heart attack or injuries sustained during an automobile accident) and thus are

not candidates for hospice care.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and Centers

for Disease Control and Prevention (CDC) mortality data from the WONDER/PC Data File. CDC’s

“Compressed Mortality” provides data through 1997 only.

Beneficiaries Use Fewer

Days of Hospice Care on

Average

Although more Medicare beneficiaries are receiving hospice services, on

average, they are receiving fewer days of care than did beneficiaries in the

past.13 From 1992 to 1998, average length of stay declined 20 percent (from

74 to 59 days), while median length of stay declined 27 percent (from 26 to

19 days).14 (See fig. 2.)

Primary diagnosis

Hospice users as a percent of decedents

aged 65 and older

1992 1997

Cancer 26% 47%

Breast 26 48

Colon 16 31

Lung 27 47

Pancreatic 30 53

Prostate 29 50

Noncancera 2 9

13Not all beneficiaries who elect the hospice benefit die while in hospice care. Each year,

between 10 and 14 percent of beneficiaries using hospice deselected the benefit. Slightly

more than half of these beneficiaries die within 30 days of the time they stop receiving

hospice services. Beneficiaries who received hospice services for longer than 6 months

were twice as likely as those enrolled for less than 6 months (25 percent versus 12 percent)

to leave hospice care alive. Similarly, beneficiaries with noncancer diagnoses were more

likely than those with cancer to disenroll from a hospice program, although the difference

was not as great—about 15 and 11 percent, respectively.

14The small proportion of beneficiaries with very long periods of enrollment skews the

average length of hospice service. Annually, more than 80 percent of new hospice entrants

complete their hospice use in the year in which they enroll, and 97 percent complete their

hospice use by the end of the year following their initial enrollment. However, some of the

remaining beneficiaries receive services for many more years. Because records of hospice

use are not complete for beneficiaries who entered hospice during the later years of our

study period, we adjusted the claimed days of hospice service for 1996 to 1998 to better

account for beneficiaries with very long stays. See app. I for more information on our

methodology.
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Page 13 GAO/HEHS-00-182 Medicare Hospice Benefit

Figure 2: Decline in Average and Median Hospice Lengths of Service, 1992-98

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

The overall decline in average length of service appears to have been driven

by both (1) a reduction in the proportion of beneficiaries with very long

hospice stays and (2) an increase in the share of users with very short

stays.15 (See table 4.) From 1992 to 1998, the share of hospice enrollees

with more than 6 months of service use declined from 9.3 to 7.3 percent.

Over the same period, the proportion of beneficiaries who used hospice for

0

10

20

30

40

50

60

70

80

1992 1993 1994 1995 1996 1997 1998

Days

74

76 75

68

65

61

59

26 26 26

24 23

21

19

Average

Median

15The distribution of patients between cancer and noncancer diagnoses is the same for very

long (more than 6 months) and very short (1 week or less) periods of hospice use, 47

percent and 53 percent, respectively.
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Page 14 GAO/HEHS-00-182 Medicare Hospice Benefit

a very brief period before death rose sharply. In 1998, 28 percent of all

beneficiaries using hospice care did so for 1 week or less.

Table 4: Hospice Benefit Use by Weekly Intervals, 1992 and 1998

a

Includes all days of hospice care each beneficiary used.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

The decline in the average number of hospice days used has been

especially dramatic among beneficiaries with a primary diagnosis other

than cancer. While these beneficiaries historically had many more days of

care than cancer patients, the average number of days used declined 38

percent between 1992 and 1998. In comparison, average days used by

beneficiaries diagnosed with cancer declined by 14 percent. As a result,

differences in length of stay across diagnosis categories have narrowed

considerably. In 1998, cancer patients used an average of 54 days while

noncancer patients used 68 days, on average. Figure 3 compares the

decline in the average number of hospice days used for beneficiaries with

cancer and noncancer diagnoses.

Weeks of hospice care

used

Total hospice users Total hospice days useda

1992 1998 1992 1998

1 or less 20.9% 28.0% 1.2% 1.8%

2 14.5 15.2 2.1 2.7

3 9.8 9.1 2.4 2.7

4 7.2 6.4 2.4 2.7

5 to 8 17.2 14.6 9.4 10.0

9 to 12 8.6 7.7 8.0 9.0

13 to 16 5.6 5.3 7.3 8.7

17 to 26 7.0 6.4 13.6 15.6

More than 26 9.3 7.3 53.6 46.8
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Figure 3: Average Days of Use for Cancer and Noncancer Patients, 1992-98

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

At the state level, average length of service declined in 42 of 50 states and

the District of Columbia from 1992 to 1998, and variation in average length

of service across states lessened considerably. (State data appear in app.

II.) In 1992, 27 states had average service periods within 10 days of the 74-

day national average. By 1998, 36 states had average service periods within

10 days of the 59-day average.

0

20

40

60

80

100

120

140

160

180

200

Alzheimer's Disease

Congestive Heart Failure

Stroke

Chronic Obstructive Pulmonary Disease

All Cancer

1992 1993 1994 1995 1996 1997 1998

Days 
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Multiple Factors

Influence the Use of

the Hospice Benefit

Several factors influence beneficiary choice about whether and when to

use hospice care. These include physician preferences and referral

practices, individual patient choice and circumstances, and general

awareness of the benefit among the public and professional communities.

In addition, recent federal oversight of compliance with patient eligibility

requirements may have affected certain beneficiaries’ use of the hospice

benefit.

Physician Practices, Patient

Preferences, and Public

Awareness Affect Hospice

Use

Although Medicare beneficiaries and their families make the decision about

whether and when to initiate hospice services, physician willingness to

discuss options for end-of-life care is important to the decision. However,

the research literature indicates that not all physicians are comfortable

discussing end-of-life care, and some may hesitate to suggest hospice care

for other reasons, such as concerns about relinquishing control of their

patients’ care. Even when the issue has been broached, some beneficiaries

choose instead to continue curative or life-extending treatments. Patient

advocacy groups, several medical societies, and others have called for

greater public and professional awareness of options for care of the dying,

which has led to a range of educational efforts designed to increase

awareness of hospice and its benefits.

Physician Preferences and

Practices

The research literature indicates that because patients and their families

rely heavily on physician recommendations for treatment, including

recommendations for end-of-life care, physicians are an influential factor in

patient entry into hospice. Physicians initiate most referrals to hospice, and

they may continue to care for their patients after enrollment as part of the

hospice team. However, research has shown that many physicians are

poorly trained in the care of the dying and are often uncomfortable

discussing options for end-of-life care or the cessation of curative

treatment.16 A recent review of 50 top-selling textbooks from several

medical specialties found that most provided inadequate information on

end-of-life issues, with oncology textbooks among those particularly likely

16A recent study found that physicians commonly make errors in their predictions of life

expectancy, most often predicting that patients have longer to live than they really do. The

authors concluded that this may contribute to late referral to hospice care and noted that

physicians are uncomfortable making predictions of expected life span, in part because

neither medical training nor published literature treats prognostication as important. See

Christakis and Lamont, pp. 469-73.
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to provide no information about key aspects of end-of-life care.17 Physician

referral to hospice may be limited by other factors, as well. For example,

experts in the area of palliative care, as well as the research literature,

suggest that some physicians may not be aware that they can continue to

provide services after a beneficiary has entered hospice and may delay

referral out of concern about losing control of the patient’s care.18

Patient Choice and

Circumstances

The use of hospice services by Medicare beneficiaries requires not just

awareness of the benefit and a physician’s certification of prognosis but

also acceptance that death is the outcome of their illness and the choice by

beneficiaries to give up a portion of their standard Medicare benefits in

order to receive hospice care. Once enrolled, no other services related to a

patient’s terminal condition are covered under Medicare. HCFA officials

and others also noted that improvements in cancer care and the addition of

new treatment options may be prompting some beneficiaries to pursue new

curative options until very shortly before death, thus contributing to the

trend of shorter hospice stays. Other beneficiaries may favor continuing

aggressive, life-extending treatments up until the time of death and not

enter hospice at all. According to HCFA officials, it may be that some

terminal patients do not want hospice care, and that should be their right.

Research suggests that beneficiaries who do not consider hospice care may

be unwilling to confront the terminal nature of their illness, may not know

that the alternative exists, or may misunderstand the services available

through hospice care. The Institute of Medicine (IOM) noted that patients

are influenced by the general unwillingness to accept limits of all types,

including those of aging and death.19 A Gallup poll in 1996 found that

although a majority of people expressed interest in hospice care, most also

said that they would still seek curative care.

In some cases, a beneficiary’s circumstances may complicate hospice

enrollment. Hospice is designed to allow the beneficiary to remain at home

17M. W. Rabow and others, “End-of-Life Care Content in 50 Textbooks From Multiple

Specialties,” Journal of the American Medical Association, Vol. 283, No. 6 (Feb. 9, 2000), pp.

771-78.

18Visits by the patient’s attending physician are not covered by the hospice payment and

continue to be paid by Medicare part B coverage.

19IOM, Approaching Death: Improving Care at the End of Life (Washington, D.C.: National

Academy Press, 1997).
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Page 18 GAO/HEHS-00-182 Medicare Hospice Benefit

during his or her last few weeks of life, where family and friends are

expected to deliver most of the routine day-to-day care. Hospice staff offer

more specialized care and respite care to give family members a break

when they need one. Thus, some hospice programs limit participation to

beneficiaries who have a caregiver at home. Others permit such

beneficiaries to enter the hospice program with the understanding that

transfer to a nursing home will be required when their needs for assistance

reach a certain stage.20

Public and Professional

Awareness

Public and professional awareness also influences the use of the Medicare

hospice benefit. The need for greater public and professional

understanding of options for end-of-life care, including hospice, has been

highlighted in several recent congressional hearings and in other public

forums.21 In addition, several medical societies, patient advocacy groups,

and the hospice industry have undertaken a variety of efforts to educate

their members and the public about end-of-life care options. For example,

the American Medical Association and the Robert Wood Johnson

Foundation are developing a core curriculum for educating physicians in

end-of-life care. The Medicare Rights Center, a consumer advocacy and

education organization, is conducting a national campaign to increase

awareness of the Medicare hospice benefit among health professionals.

Also, the National Hospice and Palliative Care Organization has published a

variety of materials on public education and outreach strategies for its

members.

Federal Oversight of

Eligibility May Have Had an

Effect on Beneficiary Use of

Services

Industry and patient advocacy groups contend that recent federal scrutiny

of provider compliance with program eligibility requirements has

inappropriately limited access to hospice for certain beneficiaries. While

federal scrutiny may have contributed somewhat to the existing trend

toward shorter hospice enrollment periods, continued growth in the

20For a detailed discussion of hospice use by nursing home residents, see Department of

Health and Human Services, Assistant Secretary for Planning and Evaluation, Office of

Disability, Aging and Long-Term Care Policy, Use of Medicare’s Hospice Benefit by Nursing

Facility Residents (Mar. 2000).

21U.S. Senate Special Committee on Aging, “The End of Life: Improving Care, Easing Pain

and Helping Families” (July 17, 2000); U.S. House of Representatives, Committee on

Government Reform, “Improving Care at the End of Life With Complementary Medicine”

(Oct. 19, 1999); U.S. Senate, Committee on Health, Education, Labor, and Pensions, “Pain

Management and Improving End-of-Life Care” (Oct. 13, 1999).
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Page 19 GAO/HEHS-00-182 Medicare Hospice Benefit

number of beneficiaries receiving hospice services makes it difficult to

identify the extent to which federal scrutiny may have deterred access.

Furthermore, the use of hospice services has increased most rapidly among

beneficiaries with diagnoses other than cancer—those for whom arriving at

a 6-month prognosis may be more difficult.

In 1995 and 1996, the Department of Health and Human Services’ (HHS)

Office of the Inspector General (OIG) investigated the eligibility status of

Medicare beneficiaries receiving hospice services as part of a larger

investigation of fraud and abuse in Medicare. Specifically, OIG reviewed

the admission decisions made for hospice patients with very long stays at

12 hospices in four states; it found that many of these patients did not meet

eligibility criteria upon admission to hospice. OIG followed this effort with

other reviews of beneficiary eligibility, encompassing a larger sample of

hospices, and found that the vast majority of Medicare beneficiaries

receiving hospice services were eligible for such services.22

Patient advocacy groups and the hospice industry assert that this federal

scrutiny of compliance with the 6-month eligibility rule has had a chilling

effect on entry into hospice for noncancer beneficiaries, for whom it may

be more difficult to establish a 6-month prognosis with confidence. They

contend that hospice providers are more cautious about admitting

beneficiaries with noncancer diagnoses as a result, leading to delays in

hospice entry for persons wishing to use the benefit. Although the

percentage increase in beneficiaries electing hospice slowed somewhat

from 1995 through 1998 compared with the prior period, it is difficult to

know what portion of this slower growth is attributable to the effect of

federal scrutiny and what portion is attributable to other factors, such as

the larger base of beneficiaries already using hospice.

The OIG scrutiny of beneficiary eligibility may have contributed to later

hospice entry for some beneficiaries, to the extent that hospice providers

responded to the oversight with greater caution about beneficiary

eligibility. However, the trend toward fewer days of hospice use began

22OIG reported that 81 percent of beneficiaries in its sample were eligible for hospice care,

while 7 percent were ineligible. OIG was not able to determine eligibility for 12 percent of

beneficiaries. A larger proportion of hospice beneficiaries in nursing homes were found

ineligible. See HHS, Medicare Hospice Beneficiaries: Services and Eligibility, pub. OEI-04-93-

00270 (Apr. 1998). For a discussion of the OIG report, see HHS, Assistant Secretary for

Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy, Important

Questions for Hospice in the Next Century (Mar. 2000).
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Page 20 GAO/HEHS-00-182 Medicare Hospice Benefit

before the period of federal scrutiny. As shown in figure 4, the average

length of service for both cancer and noncancer hospice users peaked by

1994, before scrutiny of the hospice benefit increased. Furthermore,

physician groups we spoke with did not cite caution among hospice

providers about beneficiary eligibility as a primary barrier to the initiation

of hospice services for their patients. According to the American Society of

Clinical Oncology, barriers to timely hospice care for cancer patients

include the attitudes of physicians and patients toward death and

reluctance to talk about death until the very end of life.
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Page 21 GAO/HEHS-00-182 Medicare Hospice Benefit

Figure 4: Decline in Average and Median Days of Hospice Care for Cancer and Noncancer Patients, 1992-98

Note: Operation Restore Trust (ORT) was a joint initiative among HCFA, OIG, and the Administration

on Aging designed to identify vulnerabilities in the Medicare program.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

0

20

40

60

80

100

120

1992 1993 1994 1995 1996 1997 1998

Days

ORT

Investigations

Begun

First OIG Report

on Hospice

Issued

Average Days Used, Noncancer

Average Days Used, Cancer

Median Days Used, Cancer

Median Days Used, Noncancer
B-284476

Page 22 GAO/HEHS-00-182 Medicare Hospice Benefit

While the OIG reviews were under way, the National Hospice Organization

developed guidelines to assist physicians and hospices in determining a 6-

month prognosis for patients with selected noncancer diagnoses. These

included amyotrophic lateral sclerosis (ALS), dementia, human

immunodeficiency virus (HIV)/acquired immunodeficiency syndrome

(AIDS), heart disease, pulmonary disease, liver disease, stroke and coma,

and kidney disease. In order to enhance accuracy and uniformity in the

claims review process, HCFA distributed these guidelines to the

intermediaries that process hospice claims for Medicare to use in assessing

compliance with benefit requirements.23 The intermediaries have since

adopted these guidelines as formal local medical review policies.24

Concerns have been raised that using these guidelines as a standardized

basis for determining Medicare hospice eligibility limits access to hospice,

particularly for patients with noncancer diagnoses. Industry

representatives assert that the guidelines require further development to

improve prognostic confidence and accuracy before they would be

appropriate as formal medical review policies.

However, intermediaries point out that while medical review policies

specify clinical criteria for establishing a patient’s 6-month prognosis, they

allow for variation in individual cases. For example, one intermediary’s

medical review policy for heart disease notes that “some patients may not

meet the criteria, yet still be appropriate for hospice care, because of other

comorbidities or rapid decline.” According to Medicare program guidance

to all hospices, the fact that a hospice patient lives beyond 6 months does

not, by itself, constitute grounds for a determination that the patient was

never eligible for hospice care or that Medicare does not cover services

provided to the patient. Typically, if a question is raised as to whether a

patient is terminally ill, the intermediary asks the hospice to furnish

23Intermediaries contract with HCFA for paying providers for services provided to Medicare

beneficiaries. They review all hospice claims for accuracy and completeness before

payment and review a sample of claims to confirm that beneficiaries were eligible for the

hospice services provided.

24Local medical review policies are medical criteria, specific to a service or diagnosis, that

may assist in determining compliance with program eligibility requirements. More recently,

some intermediaries have adopted policies for adult failure to thrive, and policies for

specific cancers are also under development.
B-284476

Page 23 GAO/HEHS-00-182 Medicare Hospice Benefit

information necessary to affirm the patient’s prognosis. The rates of

medical reviews of claims began increasing in 1995, at HCFA’s direction.25

Four of the five intermediaries reported that, by 1999, review rates ranged

from 0.8 to 4.2 percent of all hospice claims processed.26

Nearly all the hospice providers we spoke with said they consult their

intermediaries’ medical review policies as part of the admission screening

process. Asked about the effect of the review policies on admitting

patients, some hospices reported that using these criteria has decreased

the likelihood of admitting patients with noncancer conditions, while

others said that the review criteria have increased the likelihood of

admissions or have had no effect at all.

Hospice Care Is More

Widely Available, but

Providers Report Cost

Concerns

Sustained growth in the number of hospice providers participating in

Medicare and in their distribution throughout the country suggests that

hospice services are now more widely available to program beneficiaries.

While all sectors of the hospice industry have grown over the past decade,

recent growth has been particularly strong in the for-profit sector and

among large hospice programs. At the same time, hospice industry officials

report growing cost pressures from shorter patient stays and changes in the

practice of palliative care. Because data on provider costs are not available,

however, it is not clear how these cost factors affect providers and

beneficiaries.

The Number of Hospice

Providers Continues to

Grow

Although the overall rate of growth has slowed somewhat in the past few

years, new hospice providers continue to enter the Medicare program

every year. As shown in figure 5, the number of Medicare-certified hospice

providers nationwide grew by 82 percent from 1,208 in 1992 to 2,196 in

25Claims are selected for medical review on the basis of a variety of factors, including

beneficiary length of stay, beneficiary diagnosis, and provider use of hospice continuous

home care or inpatient care. Before 1995, intermediaries reviewed a very small proportion

of hospice claims.

26One fiscal intermediary did not provide consistent data on rates of medical review.
B-284476

Page 24 GAO/HEHS-00-182 Medicare Hospice Benefit

1999.27 Each year during the period, additional hospice programs became

certified for Medicare, although the number of new entrants declined from

274 in 1994 to 46 in 1999, and the number of hospices leaving Medicare

exceeded the number of new entrants in 1999. (Many of those leaving were

based in home health agencies (HHA) that may have closed because of

changes in HHA payments enacted in BBA.) The increased number reflects

not only new hospices but also growing participation in Medicare. (See

app. II for more detail on changes in hospice supply and distribution.) In

1989, we estimated that only about 35 percent of the approximately 1,700

hospice providers nationwide participated in Medicare. By 1998, the

National Hospice and Palliative Care Organization estimated that 80

percent of hospices were certified to serve Medicare patients.

27The total number of Medicare hospice providers peaked at 2,281 in 1998. In 1998 and 1999,

the 195 hospice program closures exceeded the 149 new program entrants for the first time.

A disproportionate number of hospice closures were among those based in home health

agencies (HHA). Although HHA hospices represent approximately one-third of all hospices,

they accounted for 43 percent of those that closed over the 2-year period. As we reported in

Medicare Home Health Agencies: Closures Continue, With Little Evidence Beneficiary

Access Is Impaired (GAO/HEHS-99-120, May 26, 1999), 14 percent of HHAs closed between

October 1997 and January 1999.
B-284476

Page 25 GAO/HEHS-00-182 Medicare Hospice Benefit

Figure 5: Growth in the Number of Medicare Hospices and New Entrants, 1992-99

Source: GAO analysis of annual Medicare Provider of Service Files.

0

500

1,000

1,500

2,000

2,500

1992 1993 1994 1995 1996 1997 1998 1999

Number

1,208

1,433

1,667

1,910

2,129

2,238 2,281

2,196

193 240 274 266 243

174

103 46

Active Providers

New Entrants
B-284476

Page 26 GAO/HEHS-00-182 Medicare Hospice Benefit

Over this period, all types of hospice providers grew, in rural and urban

areas and in almost every state. From 1992 to 1999, the rate of growth was

greatest among for-profit providers and those in rural areas. Also, large

providers accounted for an increasing share of the services delivered. (See

table 5.) The number of for-profit providers increased nearly fourfold, and

the number of large hospice programs (those serving 500 or more Medicare

patients per year) more than tripled over the period.28 In addition, the

number of rural providers increased by 116 percent while the number of

urban-based providers increased 64 percent. Even with high growth in

these sectors of the industry, the majority of hospices are small programs

(with fewer than 100 Medicare patients per year), organized as not-forprofit, and located in urban areas.

28For-profit hospices provided about 30 percent of the hospice days beneficiaries used in

1998, up from 18 percent in 1992. Large hospices (those serving 500 or more patients in a

year) provided 38 percent of hospice days in 1998 compared with 28 percent in 1992.
B-284476

Page 27 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 5: Growth in Medicare Hospice Programs by Provider Characteristics, 1992

and 1999

Note: Detailed information was not available for all providers.

a

We categorized hospices small if they served fewer than 100 Medicare beneficiaries during the year,

medium if they served 100 to 499 patients per year, and large if they served 500 or more beneficiaries

per year.

b

We categorized a hospice urban if it was located within a metropolitan statistical area (MSA) and rural

if it was located outside an MSA.

Source: GAO analysis of annual Medicare Provider of Service Files.

Even with certificate-of-need (CON) requirements that apply to hospice

providers in 14 states, the number and size of Medicare hospice providers

increased in almost every state from 1992 to 1998.29 Among states with

large Medicare enrollment and no CON requirements, the most dramatic

growth was in Texas, where the supply of hospice providers relative to the

Characteristic

Number of hospices Percent change

1992 1999 1992-99

All hospices 1,208 2,196 82%

Affiliation

Freestanding 466 877 88

Hospital-based 327 553 69

HHA-based 403 730 81

Control

For-profit 151 593 293

Not-for-profit 957 1,365 43

Government 63 146 132

Other 36 75 108

Sizea

Small 795 1,244 56

Medium 370 816 121

Large 43 136 216

Locationb

Urban 823 1,350 64

Rural 384 829 116

29In 14 states, a hospice may be required to obtain a CON before becoming eligible to

provide services. CON programs are run by state planning or regulatory agencies and are

designed to limit the numbers of providers of a given type, based on established formulas or

criteria for need.
B-284476

Page 28 GAO/HEHS-00-182 Medicare Hospice Benefit

size of the Medicare population nearly doubled. Among the CON states

with large Medicare populations, providers increased the number of

patients served, while growth in the number of providers was constrained.

For example, in Florida and New York the number of hospices per million

beneficiaries remained virtually unchanged; however, the number of

beneficiaries each hospice served grew 66 and 105 percent, respectively.

(See table 6.)

Table 6: Growth in Number and Size of Hospices in States With Large Medicare

Populations, 1992 and 1998

Note: These 10 states combined accounted for 54 percent of all Medicare enrollees in 1998.

Source: GAO analysis of annual Medicare Provider of Service Files.

Industry Reports Increased

Cost Pressures but the

Effect on Providers Is

Uncertain

Even as the hospice industry has grown, changes in the use of the hospice

benefit and the delivery of hospice care have raised concerns about cost

among providers. Most significantly, declines in the average enrollment

period have resulted in fewer days over which providers can spread the

fixed costs associated with a patient’s stay in hospice. In addition,

providers report that changes in the practice of palliative medicine have

made the use of higher-cost services more common. However, because

reliable data on provider costs are not available, it is not clear how these

factors may effect hospices’ financial status or their ability to serve

Medicare beneficiaries.

State

1992 1998

Providers

per million

beneficiaries

Hospice

users per

provider

Providers

per million

beneficiaries

Hospice

users per

provider

U.S. total 35 118 60 157

California 25 152 48 189

Florida (CON) 15 579 14 961

Illinois 30 155 54 183

Michigan 39 133 54 219

New Jersey 29 141 37 210

New York (CON) 19 158 20 325

North Carolina (CON) 62 80 63 131

Ohio 36 129 53 212

Pennsylvania 30 85 56 155

Texas 35 153 69 162
B-284476

Page 29 GAO/HEHS-00-182 Medicare Hospice Benefit

Industry representatives point out several areas of change that they

contend are adversely affecting the financial condition of providers.

Specifically,

• Under Medicare’s per diem payment system for hospice care, hospices

have traditionally offset the higher-cost days that occur at admission

and during the period immediately preceding death with lower-cost days

of less intensive care.30 For example, costs for admitting and assessing a

new patient, establishing a care plan, and delivering medical equipment

are incurred during the first few days of enrollment and do not vary with

the patient’s period of service. As enrollment periods have declined,

hospices have had fewer days over which they can spread the higher

costs associated with the start and end of a patient’s stay.

• As more patients enter hospice later in the course of their terminal

illness, they enter with higher levels of impairment and in need of more

intensive services. In addition, the shift in the mix of patients by

diagnosis may have increased the average service needs for the overall

hospice population. According to the most recent National Home and

Hospice Care Survey, hospice patients with noncancer diagnoses are

somewhat more likely than those with cancer to be functionally

impaired and thus may require more services on a regular basis from

hospice agencies. 31

• Physicians and patients are calling on hospice programs to provide a

broader array of palliative services than in the past. Costly treatments

such as chemotherapy and radiation—traditionally used for curative

purposes—are increasingly used in the hospice setting to manage pain

and other symptoms. Furthermore, some new palliative care treatment

options, such as the transdermal administration of narcotic pain

medication, may offer better symptom control for some patients but

often at greater expense.

To the extent that hospice providers believe that Medicare payments do not

adequately cover their costs, they may have an incentive to limit their

acceptance of patients who need more intensive services or limit the types

30Hospice representatives we interviewed reported that the hours of nursing, social work,

and administrative time the typical patient requires are nearly twice as high during the first

and last weeks of a patient’s care as they are during the intervening weeks.

31National Center for Health Statistics, The National Home and Hospice Care Survey: 1996.
B-284476

Page 30 GAO/HEHS-00-182 Medicare Hospice Benefit

and amount of services they make available.32 Providers may also respond

by choosing not to admit patients who are expected to be more expensive.

However, hospice officials we interviewed reported being able to enroll

most patients who were referred. With the exception of patients lacking

sufficient informal caregiver support, the potential cost of care and

payment rates were not generally cited as factors limiting the admission of

eligible patients.

Data to assess how declining patient stays and changes in palliative care

practices affect overall provider costs are not currently available. While

certain more expensive services may be provided more frequently, the

share of total costs that these services currently represent is unknown.33

Furthermore, we do not know the extent to which providing more

expensive medications or treatments to hospice patients may reduce the

need for other services such as nursing visits. In response to BBA

requirements, HCFA has begun collecting hospice cost data to use in

evaluating the adequacy of current levels of Medicare reimbursement.

Officials anticipate that audited hospice cost data will be available

beginning in late 2001.

Conclusion Trends in the use of the Medicare hospice benefit during the 1990s indicate

that beneficiaries with all types of terminal illnesses are making use of

hospice services in greater numbers every year. In particular, the types of

patients selecting hospice have expanded broadly—from mostly

beneficiaries with cancer to a nearly even split among those with cancer

and those with other terminal conditions. In spite of these trends in use,

and the widespread availability of hospice providers, patient advocates and

the industry are concerned about the trend toward using fewer days of

hospice care. Because many factors influence the use of hospice care, and

potential demand is difficult to determine, the extent to which the

Medicare hospice benefit may be underutilized is not clear.

32IOM has expressed concern that Medicare’s current system of paying a fixed amount per

day may discourage the provision of care for some patients, such as the use of costly pain

medications or equipment or the provision of late-night nursing visits or extensive

counseling services. See IOM, Approaching Death: Improving Care at the End of Life.

33Initial Medicare hospice rates were based on data from HCFA’s 1980-82 hospice

demonstration project, allocated over an average beneficiary enrollment period of 70 days.

The rates took into consideration the kinds of services furnished, their cost, and the

frequency of their provision at that time.
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Page 31 GAO/HEHS-00-182 Medicare Hospice Benefit

Agency Comments We provided a draft of this report to HCFA for review. In its comments,

HCFA discussed the importance of the hospice benefit to the Medicare

program and efforts to ensure that beneficiaries, physicians, and hospice

providers understand the benefits’ coverage and eligibility criteria.

Furthermore, HCFA stated that it does not believe the underutilization

concerns of hospice advocates and the industry should be discounted. It

noted that enrollment in hospice may not be an option for beneficiaries

who lack family support at home or that it may be delayed for patients who

wish to continue curative care treatments. HCFA’s comments appear in

appendix III. The agency made technical comments that we incorporated

where appropriate.

As we agreed with your office, unless you publicly announce the report’s

contents earlier, we plan no further distribution of it until 30 days after the

date of this letter. We will then send copies to the Honorable Donna

Shalala, Secretary of HHS; the Honorable Min DeParle, Administrator of

HCFA; and others who are interested. We will also make copies available to

others on request.

If you or your staff have any questions, please call me at 202-512-7119 or

Rosamond Katz, Assistant Director, at 202-512-7148. Other major

contributors were Eric Anderson, Jenny Grover, Wayne Turowski, and Ann

White.

Janet Heinrich

Associate Director, Health Financing and

Public Health Issues
Page 32 GAO/HEHS-00-182 Medicare Hospice Benefit

Appendix I

Methodology for Developing Information on Apendxies

Medicare Hospice Use and Hospice Providers ApendxiI

Our study is an analysis of national hospice enrollment, use patterns, and

industry developments from 1992 through 1998. We examined Medicare

beneficiary claims data for hospice services to determine hospice use rates

for different groups of beneficiaries. We also gathered descriptive

information about the hospices that provided the services.

We used the Medicare Hospice Standard Analytic File of the Health Care

Financing Administration (HCFA) to identify beneficiaries who enrolled in

hospice during the study period and to determine their pattern of hospice

use. To conduct an analysis of hospice enrollment by year, we assigned

beneficiaries to the year of their first hospice claim. We excluded

beneficiaries from our analysis if total payment for a beneficiary was less

than $75 or was $1 million or more, if a beneficiary at the time of a first

hospice claim was younger than 20 or older than 110, or if a beneficiary’s

residence was not in one of the 50 states or the District of Columbia.

Our analysis of beneficiary use includes information on

• age at the time of entry into hospice (younger than 65, 65 to 74, 75 to 84,

85 and older),

• gender,

• race and ethnicity (white, black, Hispanic, and other),

• state of residence,

• enrollment in managed care or fee-for-service Medicare (based on status

in the month of death, from the HCFA denominator file), and

• primary diagnosis (three-digit International Classification of Disease

code).

Analysis of the beneficiary claims data showed that 98 percent of

beneficiaries had only one hospice provider, and 97 percent had only one

diagnosis code. Therefore, we conducted all further analysis on the basis of

the provider and diagnosis listed in the first hospice claim for each

beneficiary. We calculated the period of enrollment by summing the

number of days covered by each claim, even if they covered discontinuous

periods of service, and excluded duplicate claims.1 Because records of

hospice use are not complete for beneficiaries who entered hospice during

the later years of our study period, we adjusted the claimed days of hospice

service for 1996 to 1998 to better account for beneficiaries with very long

1

Our analysis showed that 95 percent of all beneficiaries during the period of our analysis

received hospice services during one continuous time period.
Appendix I

Methodology for Developing Information on

Medicare Hospice Use and Hospice Providers

Page 33 GAO/HEHS-00-182 Medicare Hospice Benefit

stays.2 Our adjustment factor was calculated from 1992-95 data on the

proportion of total beneficiary claim days accounted for within the first 2

calendar years of hospice use.

We also described hospice use rates among different groups of Medicare

decedents. To calculate the rate of hospice use, we identified the number of

Medicare decedents each calendar year who had used hospice before

death. We used the HCFA Denominator File to identify all Medicare

decedents belonging to each demographic group in our analysis.3 Because

the HCFA Denominator File does not contain information about

beneficiary diagnosis, we used Centers for Disease Control and Prevention

(CDC) mortality data to determine the number of deaths among people

aged 65 and older.4

We used annual Medicare Provider of Service Files to identify hospice

characteristics. These files contain data on provider certification and

status, such as facility and service characteristics, provider type, and

location. We included hospices that received total Medicare payments of

$75 or more during our study period. The provider identification number

from the first hospice claim for each beneficiary was matched with the

Provider of Service file data available for that provider. We characterized

providers by

• type of control (profit, not-for-profit, or government),

• affiliation (freestanding, hospital-based, home health agency, and skilled

nursing facility),

• state,

• urban or rural location, and

• number of Medicare beneficiaries receiving services from each hospice

each year (small defined as fewer than 100 beneficiaries, medium

2

The small proportion of beneficiaries with very long periods of enrollment skews the

average length of hospice service. Although 97 to 98 percent of all those electing hospice

complete their hospice use by the end of the year following their initial enrollment, our data

for 1992 and 1993 show that some of the remaining 2 to 3 percent of beneficiaries may

receive services for as many as 6 or 7 years.

3

The HCFA Denominator File includes information about all Medicare beneficiaries with

entitlement (eligible for Medicare part A or part B) in a given year. We excluded decedents

who were not eligible for Medicare part A benefits as well as those who lived outside the 50

states and the District of Columbia.

4

Data collected from the dataset Compressed Mortality. This file provides mortality data

through 1997 only.
Appendix I

Methodology for Developing Information on

Medicare Hospice Use and Hospice Providers

Page 34 GAO/HEHS-00-182 Medicare Hospice Benefit

defined as 100 to 499 beneficiaries, and large defined as 500 or more

beneficiaries).
Page 35 GAO/HEHS-00-182 Medicare Hospice Benefit

Appendix II

Patterns and Trends in Hospice Supply and

Use ApendxiI

Table 7: Number of Hospice Providers by Control, Affiliation, Size, and Location, 1992-99

Note: Detailed information was not available for all providers.

a

Small = fewer than 100 patients a year. Medium = 100-499 patients a year. Large = 500 or more

patients a year.

b

Urban = metropolitan statistical area. Rural = nonmetropolitan statistical area.

Source: GAO analysis of annual Medicare Provider of Service Files.

Category 1992 1993 1994 1995 1996 1997 1998 1999

Percent

change

1992-99

Total providers 1,208 1,433 1,667 1,910 2,129 2,238 2,281 2,196 82%

New entrants 193 240 274 266 243 174 103 46 -76

Departures and closures 6 7 32 26 34 60 118 77 1,183

Control

For-profit 151 220 303 410 531 599 623 593 293

Not-for-profit 957 1,088 1,201 1,313 1,384 1,418 1,425 1,365 43

Government 63 83 107 120 137 140 144 146 132

Other and unknown 37 42 56 67 77 81 89 92 149

Affiliation

Freestanding 466 548 615 699 774 836 877 877 88

Hospital-based 327 371 420 476 526 557 570 553 69

HHA-based 403 502 615 713 804 814 802 730 81

Skilled nursing facility (SNF)

based 11 11 14 19 20 22 21 19 73

Sizea

Small 795 923 1,041 1,204 1,327 1,350 1,313 1,244 56

Medium 370 458 551 620 697 768 829 816 121

Large 43 52 75 86 105 120 139 136 216

Locationb

Urban 823 954 1,073 1,231 1,357 1,421 1,423 1,350 64

Rural 384 478 591 676 767 808 847 829 116
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 36 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 8: Percentage of Hospice Providers by Control, Affiliation, Size, and Location, 1992-99

a

Small = fewer than 100 patients a year. Medium = 100-499 patients a year. Large = 500 or more

patients a year.

b

Urban = metropolitan statistical area. Rural = nonmetropolitan statistical area.

Source: GAO analysis of annual Medicare Provider of Service Files.

Category 1992 1993 1994 1995 1996 1997 1998 1999

Certified providers 1,208 1,433 1,667 1,910 2,129 2,238 2,281 2,196

Control

For-profit 13% 15% 18% 21% 25% 27% 27% 27%

Not-for-profit 79 76 72 69 65 63 62 62

Government 5 66 6 6 6 6 7

Other and unknown 3 33 3 3 3 3 4

Affiliation

Freestanding 39% 38% 37% 37% 36% 37% 38% 40%

Hospital-based 27 26 25 25 25 25 25 25

HHA-based 33 35 37 37 38 36 35 33

SNF-based 1 1 1 1 1 1 1 1

Sizea

Small 66% 64% 62% 63% 62% 60% 58% 57%

Medium 31 32 33 32 33 34 36 37

Large 4 4 5 5 5 5 6 6

Locationb

Urban 68% 67% 64% 64% 64% 63% 62% 61%

Rural 32 33 35 35 36 36 37 38
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 37 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 9: Average Number of Days Beneficiaries Used Hospice by Provider Control, Affiliation, Size, and Location, 1992-98

a

Small = fewer than 100 patients a year. Medium = 100-499 patients a year. Large = 500 or more

patients a year.

b

Urban = metropolitan statistical area. Rural = nonmetropolitan statistical area.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and provider

data from annual Medicare Provider of Service Files.

Category 1992 1993 1994 1995 1996 1997 1998

Percent change

1992-98

All U.S hospices 73.9 75.7 74.7 67.6 64.8 61.4 59.3 -20%

Control

For-profit 83.1 87.1 87.7 79.8 77.8 74.6 71.4 -14

Not-for-profit 72.1 73.3 71.8 64.4 61.0 57.2 55.4 -23

Government 75.8 71.8 70.6 65.9 65.4 61.6 58.4 -23

Affiliation

Freestanding 81.7 83.6 81.0 73.4 70.6 66.9 64.5 -21

Hospital-based 69.9 71.1 70.5 63.1 61.3 57.6 54.0 -23

HHA-based 64.4 66.8 67.9 61.5 57.7 54.5 53.7 -17

SNF-based 53.4 55.4 61.2 55.9 47.3 50.8 51.7 -3

Sizea

Small 75.1 76.2 74.4 70.4 69.2 65.9 66.6 -11

Medium 73.2 75.3 74.9 67.5 64.2 61.3 59.5 -19

Large 74.0 76.0 74.6 66.2 63.5 59.4 56.3 -24

Locationb

Urban 72.1 74.3 73.7 66.6 63.7 60.4 58.0 -20

Rural 86.8 85.2 81.2 73.9 71.8 67.6 66.9 -23
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 38 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 10: Use of Medicare Hospice Benefits by Cancer and Noncancer Patients, 1992-98

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and provider

data from annual Medicare Provider of Service Files.

Category 1992 1993 1994 1995 1996 1997 1998

Percent

change

1992-98

Medicare enrollees 34,852,914 35,557,195 36,169,499 36,758,101 37,268,560 37,633,245 37,998,035 9%

Medicare decedents 1,633,088 1,718,881 1,733,054 1,770,360 1,791,588 1,806,655 1,833,053 12

Hospice users 143,110 180,097 223,044 258,481 294,931 325,324 358,949 151

Cancer patients 108,232 128,678 151,701 169,080 182,038 195,114 206,190 91

Noncancer patients 34,878 51,419 71,343 89,401 112,893 130,210 152,759 338

Average days used 73.9 75.7 74.7 67.6 64.8 61.4 59.3 -20

Cancer 62.5 63.2 63.6 60.5 58.4 55.8 53.9 -14

Noncancer 109.2 106.9 98.4 80.9 76.3 70.6 67.8 -38

Median days used 26 26 26 24 23 21 19 -27

Cancer 26 27 27 26 25 23 23 -12

Noncancer 25 26 25 21 18 16 15 -40
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 39 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 11: Number of Hospice Users by Selected Common Diagnoses, 1992-98

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

Primary diagnosis 1992 1993 1994 1995 1996 1997 1998

Percent

change

1992-98

All patients 143,110 180,097 223,044 258,481 294,931 325,324 358,949 151%

Cancer 108,232 128,678 151,701 169,080 185,038 195,114 206,190 91

Breast 7,602 8,761 10,476 11,626 12,296 12,661 13,093 72

Colon 6,697 8,402 9,426 10,722 11,762 12,401 13,278 98

Lung 29,966 35,528 41,694 46,747 51,772 54,940 57,841 93

Pancreatic 6,359 7,597 8,860 9,771 10,592 11,371 12,116 91

Prostate 10,052 11,808 13,577 14,368 15,441 15,249 15,494 54

Other 47,556 56,582 67,668 75,846 83,173 88,492 94,368 98

Noncancer 34,878 51,419 71,343 89,401 112,893 130,210 152,759 338

Alzheimer's 1,591 2,549 4,060 6,050 7,839 9,608 11,836 644

Stroke 2,140 3,528 5,426 6,972 8,973 10,910 13,282 521

Chronic obstructive

pulmonary disease 4,112 6,407 8,506 9,975 11,911 14,041 15,765 283

Congestive heart failure 6,141 9,118 12,432 15,172 18,293 20,661 24,248 295

“Ill-defined” conditions 888 991 1,306 1,651 2,593 4,845 7,599 756

Other 20,006 28,826 39,613 49,581 63,284 70,145 80,029 300
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 40 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 12: Percentage of Hospice Users by Selected Common Diagnoses, 1992-98

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

Primary diagnosis 1992 1993 1994 1995 1996 1997 1998

All patients 143,110 180,097 223,044 258,481 294,931 325,324 358,949

Cancer 75.6% 71.4% 68.0% 65.4% 62.7% 60.0% 57.4%

Breast 5.3 4.9 4.7 4.5 4.2 3.9 3.6

Colon 4.7 4.7 4.2 4.1 4.0 3.8 3.7

Lung 20.9 19.7 16.7 18.1 17.6 16.9 16.1

Pancreatic 4.4 4.2 4.0 3.8 3.6 3.5 3.4

Prostate 7.0 6.6 6.1 5.6 5.2 4.7 4.3

Other 33.2 31.4 30.3 29.3 28.2 27.2 26.3

Noncancer 24.4% 28.6% 32.0% 34.6% 38.3% 40.0% 42.6%

Alzheimer's 1.1 1.4 1.8 2.3 2.7 3.0 3.3

Stroke 1.5 2.0 2.4 2.7 3.0 3.4 3.7

Chronic obstructive pulmonary disease 2.9 3.6 3.8 3.9 4.0 4.3 4.4

Congestive heart failure 4.3 5.1 5.6 5.9 6.2 6.4 6.8

“Ill-defined” conditions 0.6 0.6 0.6 0.6 0.9 1.5 2.1

Other 14.0 15.9 17.8 19.2 21.5 21.4 22.3
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 41 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 13: Average Number of Days Beneficiaries Used Hospice by Selected Common Diagnoses, 1992-98

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File.

Primary diagnosis 1992 1993 1994 1995 1996 1997 1998

All patients 73.9 75.7 74.7 67.6 64.8 61.4 59.3

Cancer 62.5 63.2 63.6 60.5 58.4 55.8 53.9

Breast 85.1 88.0 86.3 80.4 78.1 73.9 70.0

Colon 62.8 64.6 67.3 63.8 62.1 59.8 58.6

Lung 56.7 57.1 58.0 56.2 54.6 52.5 51.0

Pancreatic 51.8 52.6 52.8 54.0 50.0 48.5 45.9

Prostate 80.6 79.7 81.5 76.9 70.8 67.4 64.5

Noncancer 109.2 106.9 98.4 80.9 76.3 70.6 67.8

Alzheimer's 173.7 180.9 156.3 125.1 113.4 100.9 99.7

Stroke 89.3 79.8 77.9 58.5 54.2 49.1 46.3

Chronic obstructive pulmonary disease 139.8 132.2 119.3 102.4 97.9 89.2 85.5

Congestive heart failure 110.7 108.2 96.7 78.8 75.3 69.1 70.9

“Ill-defined” conditions 124.8 132.4 108.6 95.6 96.9 86.4 77.9
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 42 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 14: Hospice Use and Supply by State, 1992 and 1998

State

1992 1998

Users Providers

Average

daily census

Average

days of care Users Providers

Average

daily census

Average

days of care

U.S. 143,110 1,208 24 74 358,949 2,281 23 59

Ala. 2,162 29 15 74 7,112 66 23 85

Alaska 0 0 0 0 67 3 2 53

Ariz. 3,611 16 32 53 11,098 40 37 53

Ark. 1,138 27 11 95 3,621 59 12 81

Calif. 13,251 87 28 68 34,293 181 25 53

Colo. 2,332 26 15 61 6,179 38 20 48

Conn. 1,565 9 21 46 3,951 29 15 44

Del. 568 3 36 72 1,049 5 35 63

D.C. 238 2 18 60 472 3 16 44

Fla.a 21,407 37 120 76 38,422 40 148 63

Ga. 2,276 28 14 65 9,363 62 26 68

Hawaiia 394 7 8 55 1,074 7 17 43

Idaho 615 13 11 87 1,282 30 7 62

Ill. 7,276 47 34 78 16,147 88 24 55

Ind.a 1,009 17 11 69 6,066 61 16 62

Iowa 1,601 28 14 88 4,560 59 12 60

Kans. 1,025 17 17 97 2,562 32 14 65

Kya 3,276 27 36 107 5,367 29 35 76

La. 1,462 21 12 63 4,065 38 15 57

Mainea 310 11 5 61 687 15 8 64

Md.a 1,906 22 14 58 5,387 30 22 47

Mass. 3,800 33 22 69 7,074 44 20 49

Mich. 6,670 50 26 70 16,186 74 30 56

Minn. 2,222 24 17 68 5,449 63 14 62

Miss. 611 12 12 86 2,925 39 17 94

Mo. 3,119 33 22 87 8,849 76 17 60

Mont. 402 9 10 78 1,008 17 10 65

Nebr.a 519 9 12 74 2,042 27 12 63

Nev. 794 4 43 78 2,589 9 37 50

N.H. 351 9 6 61 1,219 22 8 59

N.J. 4,652 33 25 66 9,225 44 27 50

N. Mex. 919 12 18 83 2,361 30 13 66
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 43 GAO/HEHS-00-182 Medicare Hospice Benefit

a

State has a certificate-of-need requirement for hospice.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and provider

data from annual Medicare Provider of Service Files.

N.Y.a 7,743 49 27 62 17,540 54 44 52

N.C.a 4,696 59 22 100 9,022 69 24 71

N. Dak. 343 8 9 78 983 14 9 52

Ohio 7,492 58 23 68 19,073 90 27 50

Okla. 939 14 14 72 5,946 56 23 88

Oreg. 2,483 25 19 68 6,304 42 19 49

Pa. 5,200 61 14 60 18,286 118 21 52

R.I.a 646 7 19 73 1,478 8 22 50

S.C. 1,406 16 20 83 4,050 34 22 73

S. Dak. 248 6 9 78 691 13 8 54

Tenn.a 1,522 23 13 74 4,924 60 13 61

Tex. 10,427 68 39 93 24,517 151 26 69

Utah 168 4 5 48 1,747 17 14 50

Vt.a 308 8 6 56 561 9 7 46

Va. 1,349 10 30 83 5,994 46 11 58

Wash. 2,631 20 26 72 6,845 29 32 53

W. Va.a 1,078 12 18 69 2,294 21 18 70

Wis. 2,862 41 13 70 6,231 54 17 58

Wyo. 30 3 1 54 295 12 4 65

(Continued From Previous Page)

State

1992 1998

Users Providers

Average

daily census

Average

days of care Users Providers

Average

daily census

Average

days of care
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 44 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 15: Percentage Change in Hospice Use and Supply by State, 1992-98

State Users Providers

Average

daily census

Average

days of care

U.S. 151% 89% -3% -20%

Ala. 229 128 55 15

Alaska a a aa

Ariz. 207 150 17 3

Ark. 218 119 10 -14

Calif. 159 108 -11 -22

Colo. 165 46 33 -21

Conn. 152 222 -27 -1

Del. 85 67 -5 -10

D.C. 98 50 -14 -20

Fla.b 79 8 23 -17

Ga. 311 121 83 6

Hawaiib 173 0 126 -13

Idaho 108 131 -40 -27

Ill. 122 87 -28 -31

Ind.b 501 259 42 -9

Iowa 185 111 -16 -33

Kans. 150 88 -17 -38

Ky.b 64 7 -3 -31

La. 178 81 25 -12

Maineb 122 36 66 7

Md.b 177 36 58 -19

Mass. 86 33 -5 -28

Mich. 143 48 18 -21

Minn. 145 163 -21 -9

Miss. 379 225 51 13

Mo. 184 130 -26 -31

Mont. 151 89 1 -18

Nebr.b 293 200 0 -15

Nev. 226 125 -15 -36

N.H. 247 144 30 -2

N.J. 98 33 8 -23

N. Mex. 157 150 -27 -23

N.Y.b 127 10 66 -15
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 45 GAO/HEHS-00-182 Medicare Hospice Benefit

a

Alaska had no Medicare-certified hospice providers in 1992.

b

State has a certificate-of-need requirement for hospice.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and provider

data from annual Medicare Provider of Service Files.

N.C.b 92 17 9 -29

N. Dak. 187 75 6 -32

Ohio 155 55 14 -25

Okla. 533 300 67 20

Oreg. 154 68 1 -30

Pa. 252 93 49 -13

R.I.b 129 14 16 -34

S.C. 188 113 10 -12

S. Dak. 179 117 -13 -30

Tenn.b 224 161 1 -16

Tex. 135 122 -32 -26

Utah 940 325 161 11

Va. 344 360 -37 -29

Vt.b 82 13 19 -21

Wash.b 160 45 22 -26

W. Va.b 113 75 3 -3

Wis.b 118 32 26 -17

Wyo. 883 300 241 38

(Continued From Previous Page)

State Users Providers

Average

daily census

Average

days of care
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 46 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 16: Change in Percentage of Providers, Users, and Days of Care by Provider Type, 1992-98

Note: Percentages indicate percentage shares.

a

Small = fewer than 100 patients a year. Medium = 100-499 patients a year. Large = 500 or more

patients a year.

b

Urban = metropolitan statistical area. Rural = nonmetropolitan statistical area.

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and provider

data from annual Medicare Provider of Service Files.

Category

1992 1994 1996 1998

Providers Users Days Providers Users Days Providers Users Days Providers Users Days

Control

For-profit 13% 16% 18% 18% 19% 23% 25% 24% 28% 27% 26% 30%

Not-for-profit 79 81 79 72 77 74 65 73 69 62 71 67

Government 5 2 2 6 2 2 6 2 2 6 2 2

Affiliation

Freestanding 39% 50% 55% 37% 49% 53% 36% 50% 54% 38% 52% 55%

Hospitalbased 27 20 19 25 19 18 25 19 18 25 19 17

HHA-based 33 28 25 37 30 27 38 30 27 35 29 27

SNF-based 1 2 2 1 1 1 1 1 1 1 1 1

Sizea

Small 66% 23% 23% 62% 18% 18% 62% 17% 18% 58% 15% 17%

Medium 31 49 49 33 51 51 33 50 50 36 49 50

Large 4 28 28 5 31 31 5 33 32 6 36 34

Locationb

Urban 68% 88% 86% 64% 87% 86% 64% 86% 85% 62% 86% 84%

Rural 32 12 14 35 13 14 36 14 15 37 14 16
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 47 GAO/HEHS-00-182 Medicare Hospice Benefit

Table 17: Variation in Hospice Use Among Medicare Decedents by State, 1998

State

Hospice users as percent of

Medicare decedents

Ariz. 36%

Colo. 30

Fla. 29

Oreg. 26

N. Mex. 25

Nev. 24

Mich. 23

Ohio 22

Tex. 22

Del. 21

Okla. 21

Calif. 20

Ga. 20

Ill. 20

Wash. 20

Ala. 19

Iowa 19

Utah 19

Idaho 18

Kans. 18

Ky. 18

Minn. 18

Mo. 18

R.I. 18

Hawaii 17

Md. 17

Pa. 17

Ark. 16

Conn. 16

Nebr. 16

N.H. 16

N.J. 16

N.C. 16

N. Dak. 16
Appendix II

Patterns and Trends in Hospice Supply and

Use

Page 48 GAO/HEHS-00-182 Medicare Hospice Benefit

Source: GAO analysis of claims data from the Medicare Hospice Standard Analytic File and Medicare

decedent data from the denominator file, an abbreviated version of HCFA's Medicare enrollment

database.

S.C. 16

Wis. 16

Mass. 15

Mont. 15

N.Y. 15

Ind. 14

Va. 14

W. Va. 14

La. 13

Miss. 13

Vt. 13

D.C. 12

S. Dak. 11

Tenn. 11

Wyo. 11

Maine 8

Alaska 6

U.S. total 19

(Continued From Previous Page)

State

Hospice users as percent of

Medicare decedents
Page 49 GAO/HEHS-00-182 Medicare Hospice Benefit

Appendix III

Comments From the Health Care Financing

Administration ApendxiI
Appendix III

Comments From the Health Care Financing

Administration

Page 50 GAO/HEHS-00-182 Medicare Hospice Benefit
Appendix III

Comments From the Health Care Financing

Administration

(201009) Letr Page 51 GAO/HEHS-00-182 Medicare Hospice Benefit
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