A new study shows that a medicare rule that blocks some nursing home residents from receiving simultaneous reimbursement for hospice and skilled nursing facility (SNF, a medicare-certified nursing home) care may be responsible for those residents receiving “more aggressive” treatment or hospitalization.

“This study is the first, to the knowledge of the authors, to attempt to understand how treatments and outcomes vary for nursing home residents with advanced dementia who use Medicare SNF care near the end of life and who do or do not enroll in Medicare hospice,” said researchers, whose study was published in the Journal of the American Geriatrics Society.

According to the study, around half of all nursing home residents with advanced dementia who are also dying have Medicare SNF care in the last 90 days of their life. However, those residents are not allowed under Medicare to receive hospice reimbursement for the same terminal illness. As a result, only 30% of residents with advanced dementia who have SNF care use hospice, compared to 46% of residents without SNF.

Researchers also found that residents who receive hospice care were far less likely to die in a hospital. Residents who received SNF and hospice at the same time were 87% less likely to die in a hospital, while residents who received hospice care after SNF were 98% less likely to die in a hospital.

“Unfortunately, given the high use of Medicare skilled care near the end of life and policy that prevents simultaneous Medicare reimbursement for skilled nursing and hospice care, aggressive treatments that may not be the preference of families or their loved ones are common,” said Susan Miller, lead author of the study and professor of health services policy and practice at Brown University. “What I’ve heard from physicians is that families may be advised about hospice, but when the family learns that by choosing hospice and thus giving up SNF they’d have to pay for the entire nursing home stay, they will choose SNF over hospice. One physician told me a story about a significant other who wanted hospice for their family member. It was cheaper for that person just to quit their job, stay home and care for the person and get hospice rather than to pay for nursing home care because the nursing home cost more than they were making.”

The study looked at the Medicare records of 4,344 SNF residents who had advanced dementia and died in 2006. Of those residents, only 1,086 received hospice care.

The Medicare Hospice Concurrent Care demonstration project mandated by the Affordable Care Act (colloquially known as “Obamacare”) will be investigating the issues raised by the study.