the term “hospice care” means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual’s attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program—
• (A) nursing care provided by or under the supervision of a registered professional nurse,
• (B) physical or occupational therapy, or speech-language pathology services,
• (C) medical social services under the direction of a physician,
• (D)(i) services of a home health aide who has successfully completed a training program approved by the Secretary and
o (ii) homemaker services,
• (E) medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan,
• (F) physicians’ services,
• (G) short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days,
• (H) counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death, and
• (I) any other item or service which is specified in the plan and for which payment may otherwise be made under this title.
The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home.
Hospice Terminal Diagnoses
The table also shows that the frequency of some hospice terminal diagnoses has changed over time, with relatively fewer cancer patients and relatively more non-cancer patients as a percentage of total hospice patients. Lung cancer has been recognized as the most common diagnosis among Medicare hospice patients every year since 1998. However, in 2006 non-Alzheimer’s dementia became the most common diagnosis among Medicare hospice patients. The percentage of Medicare hospice patients with lung cancer dropped from 16% in 1998 to 9% in 2009. In addition, we are seeing a notable increase in the number of neurologically-based diagnoses. We are also seeing a marked increase in non-specific diagnoses such as “Debility, Not Otherwise Specified”, and “Adult Failure to Thrive”.
Average Length of Stay
Along with the shift in the mix of hospice patients, there exists a significant increase in the average length of stay (LOS) for hospice patients. In 1998, the average LOS for hospice patients was 48 days, but by 2006 it had risen to 73 days (a 52% increase). Since 2006, the average LOS has begun to decline slightly, dropping to 71 days in 2009, which is a 48% increase from 1998. Charts 1 and 2 show that the average LOS varies by diagnosis. For the top twenty diagnoses in 2009, the average LOS ranged from 27 days for chronic kidney disease to 106 days for Alzheimer’s disease and other degenerative conditions. While the average LOS from 1998–2009 for hospice patients with diagnoses such as chronic kidney disease or cancers has remained relatively stable, the average LOS rose significantly for most other diagnoses, thought it has recently begun to decline slightly. Charts 1 and 2 graphically demonstrate the difference in the changes in lengths of stay for cancers versus other diagnoses in the top 20 list.