In the first national survey of enrollment policies at hospices, researchers from Mount Sinai School of Medicine and Yale University have found that the vast majority of hospices in the United States have at least one enrollment policy that could restrict access for terminally ill Medicare patients with high-cost medical needs. The study, which is published in the December issue of Health Affairs (http://content.healthaffairs.org/content/31/12/2690.abstract), calls for reform of Medicare reimbursement rates and hospice eligibility requirements.
Led by Melissa Aldridge Carlson, PhD, MBA Assistant Professor of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine, the research team conducted a survey of a random sample of hospice medical directors around the U.S. Of 591 hospices in the sample, 78 percent 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 health care reform in that it provides a patient-centered, multidisciplinary approach to treating patients at the end of their lives," said Dr. Aldridge Carlson. "It also reduces hospitalizations and saves health care 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. 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 one-third of hospices will enroll patients who are receiving chemotherapy; one-half will enroll patients receiving total parenteral, or intravenous, nutrition; and only two-thirds will enroll patients who want to receive palliative radiation. Larger hospices had less restrictive enrollment policies, likely because higher patient volume allows them to spread financial risk of high-cost patients across a larger patient base. Small hospices have 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," said Dr. Aldridge Carlson.
Dr. Aldridge Carlson and her team suggest that the Medicare per diem rate be increased for patients with high-cost medical needs and propose relaxing eligibility criteria for the Medicare Hospice Benefit to allow for concurrent life-extending and palliative care treatments. They also suggest that physicians who refer to hospice understand that eligibility criteria may vary widely across hospices and that larger hospices may have more expanded enrollment.
In contrast to restrictive enrollment policies, Dr. Aldridge Carlson and her team found that more than a quarter of hospices had open access policies, meaning they offered palliative care services to non-hospice patients and 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's disease," said Dr. Aldridge Carlson. "However, it is unclear if this innovative care model will spread given the rapid growth in the for-profit hospice sector."
This study was supported by grants from the National Institutes of Health.
About The Mount Sinai Medical Center
The Mount Sinai Medical Center encompasses both The Mount Sinai Hospital and Mount Sinai School of Medicine. Established in 1968, Mount Sinai School of Medicine is one of the leading medical schools in the United States. The Medical School is noted for innovation in education, biomedical research, clinical care delivery, and local and global community service. It has more than 3,400 faculty in 32 departments and 14 research institutes, and ranks among the top 20 medical schools both in National Institutes of Health (NIH) funding and by US News and World Report.
The Mount Sinai Hospital, founded in 1852, is a 1,171-bed tertiary- and quaternary-care teaching facility and one of the nation's oldest, largest and most-respected voluntary hospitals. In 2011, US News and World Report ranked The Mount Sinai Hospital 14th on its elite Honor Roll of the nation's top hospitals based on reputation, safety, and other patient-care factors. Mount Sinai is one of 12 integrated academic medical centers whose medical school ranks among the top 20 in NIH funding and US News and World Report and whose hospital is on the US News and World Report Honor Roll. Nearly 60,000 people were treated at Mount Sinai as inpatients last year, and approximately 560,000 outpatient visits took place.
For more information, visit http://www.mountsinai.org/.
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