Study: Hospice policies may restrict access for some

The vast majority of hospices in the United States have at least one enrollment policy that restricts access for terminally ill Medicare patients with high-cost medical needs, according to a study.

Researchers with Mount Sinai School of Medicine and Yale University analyzed 591 randomly-chosen hospices around the U.S. Of the hospices in the sample, 78% had at least one enrollment restriction for terminally ill Medicare patients receiving high-cost care such as chemotherapy, transfusions or palliative radiation.

“Hospice care is an ideal model of healthcare reform in that it provides a patient-centered, multidisciplinary approach to treating patients at the end of their lives,” Melissa Aldridge Carlson, PhD, MBA, the study¬ís lead author and an assistant professor of geriatrics and palliative medicine at Mount Sinai School of Medicine, said in a news release. “It also reduces hospitalizations and saves healthcare dollars.

“However, Medicare hospice reimbursement is not adjusted for cost or labor intensity, which may cause hospices to be more restrictive about whom they enroll.”

Medicare provides an average reimbursement rate of $140 per day per patient for hospice care, according to the researchers. Many patients with terminal illnesses benefit from palliative chemotherapy, radiation or blood transfusion, treatments that can cost up to $10,000 per month. Some hospices may simply be unable to afford to enroll patients wishing to receive these treatments.

Also, an increasing number of treatments such as chemotherapy for cancer are considered both life-prolonging and palliative, and the extent to which such treatments may be continued under the Medicare benefit once hospice is elected is unclear.

Some patients may also need labor-intensive care such as feeding tubes, intravenous nutrition and more frequent and intensive home visits if they do not have a caregiver, all of which add to the cost of care for hospices. Because Medicare reimbursement is not adjusted for the intensity of care, hospices may be less likely to enroll patients with these needs as well.

In the survey, hospice providers reported an average of 2.3 restrictive enrollment policies. Only a third of hospices would enroll patients who are receiving chemotherapy; half would enroll patients receiving total parenteral nutrition; and two-thirds would enroll patients who want to receive palliative radiation. Larger hospices had less restrictive enrollment policies, likely because higher patient volume allows them to spread the financial risk of high-cost patients across a larger patient base. Small hospices had the most restrictive enrollment policies.

“Our results indicate that addressing the financial risk to hospices of caring for patients with high-cost complex palliative care needs is likely a key factor to improving access to hospice care,” Aldridge Carlson said.

The researchers said the Medicare per diem rate should be increased for patients with high-cost medical needs. They proposed relaxing eligibility criteria for the Medicare Hospice Benefit to allow for concurrent life-extending and palliative care treatments. They also said physicians who refer to hospice should understand that eligibility criteria may vary widely across hospices and that larger hospices may have more expanded enrollment.

More than a quarter of hospices in the survey sample had open-access policies, meaning they offered palliative care services to non-hospice patients. Nonprofit hospices were more than twice as likely to have such policies compared with for-profit hospices.

“This emerging trend in open-access hospices may promote the use of hospice earlier in the course of a patient¬ís disease,” Aldridge Carlson said. “However, it is unclear if this innovative care model will spread given the rapid growth in the for-profit hospice sector.”

The study appears in the December issue of Health Affairs. The study abstract is available at

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