Advertisement

Medicare Hospice Policy Changes and Beneficiaries’ Rate of Live Discharge and Length-of-Stay

      Abstract

      Context

      The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays.

      Objectives

      Examine how live discharge rates and length of stay changed in relation to the policies.

      Methods

      We computed monthly hospice-level percent live discharges and length of stay using 2008−2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned).

      Results

      We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients.

      Conclusion

      Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pain and Symptom Management
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Medicare Payment Advisory Commission
        Hospice services.
        in: Report to Congress: Medicare Payment Policy, Washington D.C.2021: 307-350
      1. Medicare Payment Advisory Commission. Section 11: Other Services. In: July 2016: A Data Book - Healthcare Spending and the Medicare Program. Washington, D.C.; 2016:178-197.

        • Centers for Medicare & Medicaid Services
        Implementation of the hospice payment reforms.
        Medicare Learn Netw. 2015; MM9201: 1-6
        • 113th Congress
        Improving medicare Post-Acute Care Transformation (IMPACT) Act.
        Public Law 113-185-Oct. 2014; 6: 1-20
      2. Advisory Board. How hospices can prepare for increased federal audits under the IMPACT Act. Available at: https://www.advisory.com/daily-briefing/2014/11/07/how-hospices-can-prepare-for-increased-federal-audits-under-the-mpact-act. Published 2014. Accessed November 7, 2017.

        • Dolin R
        • Silberman P
        • Kirk DA
        • et al.
        Do live discharge rates increase as hospices approach their Medicare aggregate payment caps?.
        J Pain Symptom Manage. 2018; 55: 775-784
        • Wu S
        • Volker DL
        Live discharge from hospice.
        J Hosp Palliat Nurs. 2019; : 1https://doi.org/10.1097/njh.0000000000000547
        • Dolin R
        • Hanson LC
        • Rosenblum SF
        • et al.
        Factors driving live discharge from hospice: provider perspectives.
        J Pain Symptom Manage. 2017; 53: 1050-1056https://doi.org/10.1016/j.jpainsymman.2017.02.004
        • Dolin R
        • Holmes GM
        • Stearns SC
        • et al.
        A positive association between hospice profit margin and the rate at which patients are discharged before death.
        Health Aff. 2017; 36: 1291-1298
        • Wladkowski SP
        Live discharge from hospice and the grief experience of dementia caregivers.
        J Soc Work End-of-Life Palliat Care. 2016; 12: 47-62
        • Watson Campbell R
        Being discharged from hospice alive: the lived experience of patients and families.
        J Palliat Med. 2015; 18: 495-499https://doi.org/10.1089/jpm.2014.0228
        • Institute of Medicine
        Dying in America: Improving quality and honoring individual preferences near the end of life.
        The National Academies Press, Washington, D.C.2015
        • Schockett ER
        • Teno JM
        • Miller SC
        • Stuart B
        Late referral to hospice and bereaved family member perception of quality of end-of-life care.
        J Pain Symptom Manage. 2005; 30https://doi.org/10.1016/j.jpainsymman.2005.04.013
        • Rickerson E
        • Harrold J
        • Kapo J
        • Carroll JT
        • Casarett D
        Timing of hospice referral and families’ perceptions of services: are earlier hospice referrals better?.
        J Am Geriatr Soc. 2005; 53: 819-823https://doi.org/10.1111/j.1532-5415.2005.53259.x
        • MacKenzie MA
        • Buck HG
        • Meghani SH
        • Riegel B
        Unique correlates of heart failure and cancer caregiver satisfaction with hospice care.
        J Pain Symptom Manage. 2016; 51: 71-78https://doi.org/10.1016/j.jpainsymman.2015.09.001
        • Diamond EL
        • Russell D
        • Kryza-Lacombe M
        • et al.
        Rates and risks for late referral to hospice in patients with primary malignant brain tumors.
        Neuro Oncol. 2016; 18: 78-86https://doi.org/10.1093/neuonc/nov156
        • Miller SC
        • Kinzbrunner B
        • Pettit P
        • Williams JR
        How does the timing of hospice referral influence hospice care in the last days of life?.
        J Am Geriatr Soc. 2003; 51: 798-806https://doi.org/10.1046/j.1365-2389.2003.51253.x
        • Kelley AS
        • Deb P
        • Du Q
        • Aldridge Carlson MD
        • Sean Morrison R
        Hospice enrollment saves money for medicare and improves care quality across a number of different lengths-of-stay.
        Health Aff. 2013; 32https://doi.org/10.1377/hlthaff.2012.0851
        • Kumar P
        • Wright AA
        • Hatfield LA
        • Temel JS
        • Keating NL.
        Family perspectives on hospice care experiences of patients with cancer.
        J Clin Oncol. 2017; 35: 432-439https://doi.org/10.1200/JCO.2016.68.9257
        • Shega JW
        • Hougham GW
        • Stocking CB
        • Cox-Hayley D
        • Sachs GA
        Patients dying with dementia: experience at the end of life and impact of hospice care.
        J Pain Symptom Manage. 2008; 35: 499-507
        • Volicer L
        • Hurley A
        Hospice care for patients with advanced progressive dementia.
        Springer Publishing Company, Inc., New York, NY1998
        • Hendriks SA
        • Smalbrugge M
        • Hertogh CMPM
        • Van Der Steen JT
        Dying with dementia: symptoms, treatment, and quality of life in the last week of life.
        J Pain Symptom Manage. 2014; 47: 710-720
        • Broady TR
        • Saich F
        • Hinton T
        Caring for a family member or friend with dementia at the end of life: a scoping review and implications for palliative care practice.
        Palliat Med. 2018; 32: 643-656
        • Solomon MZ
        • Jennings B
        Palliative care for alzheimer patientsl implications for institutions, caregivers, and families.
        in: Volicer L Hurley A Hospice Care for Patients with Advanced Progressive Dementia1. Springer Publishing Company, Inc., New York, NY1998: 132-154
        • Van Der Steen JT
        • Radbruch L
        • Hertogh CM
        • et al.
        White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care.
        Palliat Med. 2014; 28: 197-209
        • Medicare Payment Advisory Commission
        Section 11: other services.
        in: June 2012: A Data Book - Healthcare Spending and the Medicare Program. Washington D.C., 2012: 183-202
        • Medicare Payment Advisory Commission
        Section 11: Other Services.
        in: July 2021 Data Book. Washington D.C., 2021: 183-204
        • Hebert LE
        • Weuve J
        • Scherr PA
        • Evans DA.
        Alzheimer disease in the United States (2010-2050) estimated using the 2010 census.
        Neurology. 2013; 80: 1778-1783https://doi.org/10.1212/WNL.0b013e31828726f5
        • Department of Health and Human Services
        Medicare Program; FY 2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform.
        Fed Regist. 2013; 78 (27923-27852)
        • Gianattasio KZ
        • Moghtaderi A
        • Lupu D
        • Prather C
        • Power MC
        Evaluation of federal policy changes to the hospice benefit and use of hospice for persons with ADRD.
        JAMA Heal Forum. 2022; 3e220900https://doi.org/10.1001/jamahealthforum.2022.0900
        • Thomas SK
        • Brooks SE
        • Mullins CD
        • Baquet CR
        • Merchant S
        Use of ICD-9 coding as a proxy for stage of disease in lung cancer.
        Pharmacoepidemiol Drug Saf. 2002; 11: 709-713https://doi.org/10.1002/pds.759
        • Medicare Payment Advisory Commission
        Hospice services.
        Report to Congress: Medicare Payment Policy. Washington D.C., 2010: 141-161
        • Teno JM
        • Plotzke M
        • Gozalo P
        • Mor V
        A national study of live discharges from hospice.
        J Palliat Med. 2014; 17: 1121-1127https://doi.org/10.1089/jpm.2013.0595
        • Stevenson DG
        • Grabowski DC
        • Keating NL
        • Huskamp HA
        Effect of ownership on hospice service use: 2005–2011.
        J Am Geriatr Soc. 2016; 64: 1024-1031https://doi.org/10.1111/jgs.14093
        • Aldridge MD
        • Schlesinger M
        • Barry CL
        • et al.
        National hospice survey results for-profit status, community engagement, and service.
        JAMA Intern Med. 2014; 174: 500-506https://doi.org/10.1001/jamainternmed.2014.3
      3. Hunt M, Rezaee ME, Luallen J, et al. Medicare hospice payment reform: a review of the literature (2013 update). Report prepared for Medicare and Medicaid Services.

        • Gandhi SO
        Differences between non-profit and for-profit hospices: Patient selection and quality.
        Int J Health Care Finance Econ. 2012; 12: 107-127
        • Huskamp HA
        • Buntin MB
        • Wang V
        • Newhouse JP
        Providing care at the end of life: do medicare rules impede good care?.
        Health Aff. 2001; 20: 204-211
        • Thompson JW
        • Carlson MDA
        • Bradley EH
        US hospice industry experienced considerable turbulence from changes in ownership, growth, and shift to for-profit status.
        Health Aff. 2012; 31: 1-15
        • Wachterman MW
        • Marcantonio ER
        • Davis RB
        • McCarthy EP
        Association of hospice agency profit status with patient diagnosis, location of care, and length of stay.
        JAMA. 2011; 305: 472
      4. Medicare Payment Advisory Commission. Section 11: Other services. In: June 2013: A Data Book - Healthcare Spending and the Medicare Program. Washington D.C.; 2013:185-205.

      5. Medicare Payment Advisory Commission. Section 11: Other services. In: June 2014: A Data Book - Healthcare Spending and the Medicare Program. Washington D.C.; 2014:177-197.

        • Morris GM
        Hospice fraud and abuse: operation restore trust and beyond.
        Am J Hosp Palliat Med. 2003; 20: 1-8
      6. Scanlon WJ. Testimony before the special committee on aging, U.S. Senate. MEDICARE: more beneficiaries use hospice, many factors contribute to shorter periods of. GAO. 2000.

        • Han B
        • Remsburg RE
        • McAuley WJ
        • Keay TJ
        • Travis SS
        National trends in adult hospice use: 1991-1992 to 1999-2000.
        Health Aff. 2006; 25: 792-799https://doi.org/10.1377/hlthaff.25.3.792
        • Medicare Payment Advisory Commission
        Hospice services.
        in: Report to Congress: Medicare Payment Policy, Washington D.C.2017: 315-342
        • Medicare Payment Advisory Commission
        Hospice services.
        in: Report to Congress: Medicare Payment Policy, Washington, D.C.2018: 321-350
      7. Medicare Payment Advisory Commission, Hospice services, In: Report to Congress: Medicare Payment Policy, Washington D.C., 2019, 309–340, Available at:http://www.medpac.gov/docs/default-source/reports/mar19_medpac_ch12_sec.pdf. Accessed June 26, 2019.

        • Medicare Payment Advisory Commission
        Hospice services.
        in: Report to Congress: Medicare Payment Policy. 2020: 1014https://doi.org/10.1111/j.1532-5415.1996.tb01887.x (Vol March.)
        • Clayton MF
        • Utz R
        • Iacob E
        • et al.
        Live hospice discharge: experiences of families, and hospice staff.
        Patient Educ Couns. 2021; 104: 2054-2059https://doi.org/10.1016/j.pec.2021.01.002
        • Hunt LJ
        • Harrison KL
        Live discharge from hospice for people living with dementia isn't “graduating”—It's getting expelled.
        J Am Geriatr Soc. 2021; 69: 1457-1460https://doi.org/10.1111/jgs.17107
        • Fine PG
        Hospice underutilization in the U.S.: the misalignment of regulatory policy and clinical reality.
        J Pain Symptom Manage. 2018; 56: 808-815https://doi.org/10.1016/j.jpainsymman.2018.08.005
      8. Public Law 111-148 - Mar. 23, 2010: an Act, entitled the patient protection and affordable care act. 111th Congr.:1-906. Available at: https://www.govinfo.gov/content/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed November 16, 2017.

        • Centers of Medicare & Medicaid Services
        Medicare program; hospice wage index for fiscal year 2012. Final rule.
        Fed Regist. 2011; 76: 47302-47352
      9. Centers of Medicare & Medicaid Services, CMS manual system: pub100-04 medicare claims processing: transmittal 3032, Dep Heal Hum Serv, 2014, Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3032CP.pdf. Accessed December 4, 2019.

        • Teno JM
        Hospice acquisitions by profit-driven private equity firms.
        JAMA Heal Forum. 2021; 2e213745https://doi.org/10.1001/jamahealthforum.2021.3745
        • Weuve J
        • Hebert LE
        • Scherr PA
        • Evans DA
        Deaths in the United States among persons with Alzheimer's disease.
        Alzheimers Dement. 2014; 10: e40-e46