The oldest of America's baby boomers are still more than a decade away from needing hospice care in great numbers, but with 10,000 boomers turning 65 every day, hospices are already preparing for the oncoming "silver tsunami."
The issue will be felt acutely in Pennsylvania, where seniors 85 and up are the fastest growing demographic block, and where more than 15 percent of the population is older than 65 -- a percentage bested by only Florida and West Virginia.
As a result, the number of U.S. hospice care services has been growing rapidly since 2000, and the number of people using such care is growing, too -- in 2000, about 23 percent of Medicare beneficiaries who died in the same year used hospice care. By 2012, that figure was close to 45 percent, and the average length of stay is up to nearly three months.
■ Disease: The medical challenge of this century about adding life to years
■ Medical marathon: Race is on to develop new antibiotics to combat resistant bacteria
■ Genome not destiny, doctors stress
■ Genetic tests outpace what insurers cover
■ High tech tools: Physicians seek to monitor patients remotely through new technologies
■ Physician stress: Studies suggest a significant increase in the level of discontent, especially among primary care doctors
Yet despite increasing acceptance and use of hospice care -- palliative, end-of-life care and pain management for the terminally ill -- there is room for growth. Over a quarter of people who died in hospice are only enrolled during their last week of life, according to a recent Medpac report. Some physicians are reluctant to suggest hospice care until death is imminent. The patient's family also may find it hard to accept the prognosis and encourage intensive medical measures to save someone's life, even when it won't do any good.
"Dying in America is seen as a medical failure, instead of a natural cycle of life," said Nancy Zionts, chief operating officer and chief program officer of Pittsburgh's Jewish Healthcare Foundation.
In 2007, Ms. Zionts and the JHF started an education, planning and outreach effort around end-of-life care called "Closure." Health networks around the country have been researching and installing programs such as this for the past 15 years.
"Advanced care planning is the opposite of health care rationing," Ms. Zionts said. "It provides the chance for people, together with their families and providers, to determine what care they want and is appropriate relative to their circumstances."
Those circumstances can shift from patient to patient and family to family -- and even caregiver to caregiver. Hospitals and physicians often have a diagnose-and-cure mentality. Many Americans share that mentality, too -- Americans who believe doctors should "always do everything possible" to keep someone alive has more than doubled since 1990, according to a 2013 survey from the Pew Research Center.
More than two-thirds of those asked about end-of-life care say other patients should be allowed to die in certain cases, but more than 30 percent of those polled say there are no such circumstances.
In 1990, only 15 percent of those polled said there was no good reason to allow a person to die.
Today, more than a third of adults polled say "they would tell their doctors to do everything possible to keep them alive -- even in dire circumstances, such as having a disease with no hope of improvement," the Pew survey said.
While those attitudes are often influenced by race and religion (as well as geography), they demonstrate the importance of educating people about hospice care, said Anzie Kelley, executive director of Good Samaritan Hospice of Pittsburgh.
But because so much end-of-life care is financed by the federal government, the nature and tone of that education is a political hot potato. A piece of the 2010 Affordable Care Act that would have reimbursed physicians who had "advanced care planning" discussions with patients was stripped out of the final bill, when political foes said such discussions amounted to "death panels" and end-of-life care rationing.
The consultations would have given patients a wide variety of end-of-life options, such as advanced directives to accept or refuse life-saving treatment, selecting a hospice program and appointing relatives as health care proxies.
The federal government has been in the hospice business since 1982, when a Medicare hospice benefit was added to the Tax Equity and Fiscal Responsibility Act, and in 1986, the Medicare hospice benefit was made permanent by Congress.
One of the reasons the benefit was introduced is because hospice care is cheaper than inpatient hospital care, and it was becoming clear by the 1980s that much of the Medicare budget was being consumed by dying patients.
According to the Medicare Payment Advisory Commission, "about a quarter of the total Medicare budget is spent on services for beneficiaries in their last year of life, and 40 percent of that is in the last 30 days of their life."
A study by Duke University in 2007 suggested that hospice reduced Medicare costs by $2,309 a person; numbers furnished by the Pennsylvania Homecare Association suggest that in-home hospice care costs $152 a day, compared to $1,960 for one day in a hospital or $252 for one day in a nursing home.
Additionally, those who use hospice care in earlier stages of terminal illness end up living on average a month longer.
Hospices help Medicare deal with a financial issue that wasn't nearly as prevalent in 1965, the year Medicare came into being.
"Medicare was not intended to deal with these [chronic, long-term] medical issues," said Judy Black, medical director of senior markets at Highmark. "People died in their homes a lot more often the year Medicare started."
The coming wave of Medicare patients naturally means that the hospice sector is expanding -- but it's also retrenching. Hospice care is shifting away from the institution and toward the home; it's increasingly coordinated with hospital outpatient care; and, for the first time, it's going to be quality-driven, with federal reimbursements tied to outcomes.
In 2013, the Centers for Medicare & Medicaid Services finalized its new Medicare rates for hospices and inpatient rehabilitation facilities (an extra 1.7 percent, or $160 million in additional payments) and new quality reporting guidelines that will take effect this July.
By way of the Affordable Care Act, hospices are subject to quality metrics just like hospitals are, and those hospice services that don't submit data or meet standards face Medicare reimbursement penalties.
Nikki Pena is a former Post-Gazette intern. First Published May 24, 2014 8:40 PM