Hospice use driven by finance rather than patient eligibility

By Sarah Guy, medwireNews Reporter

Barriers to hospice care in the USA could be more to do with individual hospices' enrollment policies than with patients' true eligibility, indicate study findings.

The results of this national survey, conducted between September 2008 and November 2009, show that over two-thirds of the 591 US hospices queried had at least one restrictive enrollment policy. For example, patients receiving chemotherapy or total parenteral nutrition may be excluded.

One of the primary reasons for the emergence of strict enrollment policies is that, to receive Medicare hospice benefit, patients with hospice needs must forgo reimbursement for curative treatment once hospice care has begun, explain the researchers.

"This artificial dichotomy between curative and palliative treatment, however, does not reflect the reality faced by many patients with end-stage diseases, who pursue such treatments with the goal of palliation and desire hospice services in conjunction with these treatments," they write in Health Affairs.

Mellissa Aldridge Carlson (Mount Sinai School of Medicine, New York, USA) and colleagues suggest that removing the Medicare benefit limitations and increasing the hospice per diem rate for patients who require complex palliative therapies could help US hospices expand their enrollment.

A total of 78% of the hospices that returned the self-completed survey reported at least one restrictive enrollment policy.

The most common restriction was against patients receiving chemotherapy, at 61%, while the least common was on patients receiving tube feeding, at 8%. On average, hospices reported 2.3 such restrictive policies.

In all, 29% of hospices had an open-access enrollment policy, with almost 30% of these having no restrictions on enrollment. Indeed, hospices with open-access policies were significantly less likely to restrict access to patients receiving total parenteral nutrition (42 vs 59%), those receiving transfusions (28 vs 43%), and those wishing to continue palliative radiation (23 vs 32%).

Furthermore, it was the larger hospices that were more likely to have no restrictive enrollment policies, with an average patient census of 202 compared with 62 for hospices with at least one restrictive policy: a significant difference.

Nonprofit hospices were also significantly more likely to have an open-access policy than for-profit establishments, at 39% versus 19%, report Aldridge Carlson et al.

"It may take changes in hospice eligibility or reimbursement to render open-access policies more economically beneficial for hospices," concludes the team.

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