Financial risk impacts use of hospice care in the U.S.

A new study reveals that financial risk plays a role in underuse of hospice care in the United States.

In a study published in the December issue of Health Affairs, researchers revealed the results of the first national survey of the enrollment policies of 591 U.S. hospices. The researchers discovered that 78 percent of hospices had at least one enrollment policy that may restrict access to hospice care.

[Also: Study finds the hospice industry has experienced turbulence]

Restrictive enrollment policies beyond Medicare hospice benefit eligibility criteria include declining patients if they are receiving such treatments as chemotherapy, total parental nutrition or palliative radiation – all high-cost treatments.

“Because the Medicare per diem hospice reimbursement rate is not adjusted for the cost or intensity of care, hospices have financial incentives to not enroll potentially high-cost patients,” the researchers wrote in their study.

Due to the financial risk associated with patients receiving high-cost treatments, larger hospices are more likely to not have restrictive enrollment policies while smaller hospices are likely to have them, said researcher Melissa Aldridge Carlson, PhD, an assistant professor of geriatrics and palliative care at the Mount Sinai School of Medicine in New York City.

“If you’re large, you can absorb or average the cost of an outlier-type patient, but if you’re small, it’s really going to be a problem, and so some of these policies may be established for that reason,” she said.

As noted in the study, smaller hospices represent a quarter of all hospices operating in the United States. In many rural communities, only one hospice is available, and that single hospice is likely to be a small one, said Aldridge Carlson.

Adding to access concerns is that for-profit hospices – the fastest growing segment of the hospice sector – have the most restrictive enrollment policies.

Given that the hospices that are most likely to be available to patients who could benefit from hospice care are ones that face the most financial risk, the researchers suggested that to increase patient access to hospice care and reduce financial risk for hospices, a number of options should be considered.

Those options include innovative models like open access enrollment policies; increasing the Medicare hospice per diem rate for patients with complex needs; redefining the population who can receive care under Medicare’s hospice benefit; and creating partnerships between hospices – in particular, smaller hospices – and, for instance, hospital-based palliative care programs.

“Thinking about financial risk for hospices and how that can translate into access to care is a new and important idea that needs to come out,” said Aldridge Carlson, “and I think the high prevalence of these enrollment restrictions shows it's a real concern for hospices.”