A Cost-Benefit Analysis of Music Therapy in a Home Hospice

Rafael Romo, MSN, RN; Lisa Gifford, MSN, RN


Nurs Econ. 2007;25(6):353-358. 

In This Article


Hospice continues to be a rapidly growing and evolving area of health care in the United States. The Medicare Payment Advisory Commission (MedPAC, 2006) notes that the number of hospice beneficiaries increased by 49% from 2000 to 2004. Looking at the 2004 National Data Set reveals that 72% of hospice patients are Medicare recipients and that Medicare pays for 86% of all patient days (National Hospice and Palliative Care Organization [NHPCO], 2005). The survey also shows that cancer diagnoses now account for less than 50% of all hospice diagnoses. Though the average length of stay (ALOS) has increased from year to year, the median length of stay has remained around 21 days (NHPCO, 2005). These findings are also noted by MedPAC.

Medicare's fixed daily rates create an absolute cost constraint on hospices; consequently, the growth in hospice brings financial pressures. Identifying when a non-cancer patient has a 6-month prognosis is problematic and is partially driving the increase in ALOS (Ferrera-Reid, 2004; MedPAC, 2006). The in creasing ALOS places some hospices at risk of reaching or exceeding the annual hospice cap, causing these hospices to receive less in reimbursements (MedPAC, 2006). Further, the hospice benefit was meant to reduce Medicare's cost of end-of-life care, leading to further financial pressures on hospices (MedPAC, 2006; Pyenson, Connor, Fitch, & Kinzbrunner, 2004).

Providing quality patient care under tight fiscal restraints is challenging. Expenses related to medication costs have increased faster than Medicare's routine care per diem rate (Nowels, Kutner, Kassner, & Beehler, 2004). Patients and families exert pressure to receive newer, more expensive drugs, believing that they are more effective even though current research does not support this belief (Weschles, Maxwell, Reifsnyder, & Knowlton, 2006). Medication waste after a patient dies is also a significant cost. Hauser, Chen, and Paice (2006) found that one hospice wasted from $109 to $206 worth of medications per patient after patients died. Other cost drivers include wages and travel expenses. Though Medicare reimbursements are adjusted regionally for salary, the rates do not account for the difficulty rural hospices (and some urban areas) face in recruiting and retaining staff (Casey, Moscovice, Virnig, & Durham, 2005). Likewise, the rates do not account for the greater distances that must be traveled in rural locations, which reduce the number of patients that can be seen in a day.

Medicare controls costs through the use of two annual caps: a cap on the average annual cost per patient and a cap on the total number of inpatient days permitted in a year (MedPAC, 2006). Unlike the per diem rates, the caps are not adjusted for regional differences. This means a hospice that is reimbursed at minimally adjusted rates can have an ALOS of 6 months, while a hospice that has a high adjustment (such as hospices in many urban areas) may need an ALOS of 3 months.

Different cost control initiatives have been studied and tried in hospice. For instance, Medicare allows hospices to pass two charges on to patients: a 5% co-payment for drugs (limited to $5 per drug) and a 5% co-payment for the cost of respite care (limited to $952 per year) (MedPAC, 2006). Private insurance companies may impose benefit caps or limit the number of days a patient is allowed to be in hospice (Deans, 2004). Medication costs are controlled by using contract pharmacies and limiting the drugs placed on approved formularies (Nowels et al., 2004). Beyond Medicare's minimum requirements, additional admission requirements are also used by some hospices, such as requiring patients to forego chemotherapy and radiation, not allowing treatments with antibiotics, and not admitting patients who reside outside their home (Lorenz, Asch, Rosenfeld, Liu, & Ettner, 2004). Hospices may also require higher caseloads for staff. This technique is easier for urban hospices with larger staffs and larger patient censuses as opposed to a rural hospice that may have a census of only five patients (Virnig, Moscovice, Durham, & Casey, 2004).

The American Music Therapy Association (AMTA, 2004) defines MT as "interventions designed to promote wellness, manage stress, alleviate pain, express feelings, enhance memory, improve communication, [and] promote physical rehabilitation." By this definition, MT is well suited to hospice as it addresses the four domains of palliative care (physiological, emotional, social, and spiritual care) identified by Cecily Saunders and adopted as components of hospice care in the United States (Deans, 2004; Saunders, 2000). Though Medicare does not require that MT services be provided by hospices, MT is increasingly being used by hospice programs (Gallagher et al., 2001).

The data from studies on the effect of MT on physiologic signs of pain is inconclusive (Hayes, Buffum, Lanier, Rodahl, & Sassos, 2003; Ikonomidou et al., 2004; Lee, Henderson, & Shum, 2004); however, other research has shown that MT improves the perception and reported level of pain (Gallagher, Lagman, Walsh, Davis, & LeGrand, 2006; Lukas, 2004). Strong evidence exists that MT decreases anxiety and stress (Gallagher et al., 2006; Hayes et al., 2003; Ikonomidou et al., 2004; Lee et al., 2004; Lukas, 2004; Pellino et al., 2005). Gerdner's (2005) finding that MT may aid in decreasing anxiety in patients with dementia is of particular interest to hospice. Though the study is small (N=8), the indications are promising for this population of hospice patients. Hsu and Lai (2004) and Gallagher et al. (2006) found MT improved mood and depression, a significant issue for the terminally ill (Mystakidou et al., 2005; Pessin, Rosenfeld, & Breitbart, 2002).

Patients with dementia, who are becoming a larger portion of hospice patients, present unique issues. Ashida (2000) found that reminiscence music significantly reduced the symptoms of depression in patients with dementia, and staff reported improved mood and interactions. MT is also effective intervention for agitation and disruptive behavior in patients with dementia, reducing the difficulty of providing care (Gerdner; 2005; Remington, 2002; Richeson & Neill, 2004).

MT has a positive effect on a number of key hospice quality indicators: quality of life, patient satisfaction, and communication. Hilliard (2003) found that just a single MT session improves quality of life and patient satisfaction and that these scores increased with the number of sessions. Other research indicates that MT decreases patient isolation, improves patients' interpersonal connections, and enables nonverbal patients to express feelings and connect with others (Chawin, 2002). MT can be used to communicate feelings and thoughts that could not otherwise be expressed (Hilliard, 2003).

The question of how MT may affect the financial performance of hospices has not been addressed in the literature. In the only study located that specifically looked at the cost benefits of MT, Walworth (2005) examined the use of MT with pediatric patients undergoing noninvasive procedures. The use of music for procedural support resulted in more successful procedures, a reduction in the use of sedation, a decrease in the length of procedures, and a decrease in the number of staff interventions with patients.

Generalizing these findings to adult patients is difficult. While not specifically studying for cost effectiveness, many researchers noted a decrease in the use of opioids and other analgesics when patients used music therapy (Ikonomidou et al., 2004; Lukas, 2004; Pellino et al., 2005). None of the research mentioned previously measured staff time; however, there is evidence that suggests MT reduces anxiety, agitation, and disruptive behavior and improves mood (Ashida, 2000; Gerdner, 2005; Madan, 2005; Sung & Chang, 2005), which suggests that staff interventions with patients would be more effective, and perhaps fewer in number.


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