‘Upgrading’ the Medicare Hospice Benefit

The Medicare Hospice Benefit could use an “upgrade” to ensure greater flexibility that may be necessary to fully support patients’ needs.

This is according to a recent editorial in Health Affairs by Cara L. Wallace, the Dorothy A. Votsmier Endowed Chair and a professor in the Valentine School of Nursing at Saint Louis University, and Stephanie P. Wladkowski, the Larry and Patty Benz Professor and an associate professor of social work at Bowling Green State University.

Among the changes that the U.S. Centers for Medicare & Medicaid Services (CMS) should consider is retiring the six-month terminal prognosis requirement and allowing for some concurrent care, Wallace and Wladkowski indicated.

“These restrictions are closely tied to the two most common reasons for a live discharge from hospice: decertification — when a patient is removed from hospice care due to a stabilized condition; or revocation — when a patient chooses to leave hospice care to seek curative care,” the authors wrote. “Both are challenging and disruptive and are the result of inflexibility in current policy.”

A clear example is the impact that these policies can have on dementia patients.

Dementia-related illnesses have become one of the most frequently occurring principal diagnoses among hospice patients, tied with cancer, according to the National Hospice and Palliative Care Organization (NHPCO).

In Fiscal Year 2022, 7.5% of the nation’s 1.7 million hospice recipients were diagnosed with Alzheimer’s disease, 6.8% with senile degeneration of the brain and 3.5% with late-onset Alzheimer’s disease, NHPCO reported. This is compared to 4.3% with chronic obstructive pulmonary disease and 2.8% for heart failure, among other diagnoses.

Patients with dementia often have longer hospice stays and require more intensive and expensive levels of care compared to others. A key consideration is that dementia patients have a less predictable course than those with cancer, for whom the hospice benefit was initially designed.

“Today, the requirement of a six-month prognosis is outdated. Chronic illnesses—such as Alzheimer’s disease and related dementias, stroke (cerebrovascular accident), and lung and heart diseases (that is, chronic obstructive pulmonary disease, congestive heart failure) — have a less predictable health trajectory, making a six-month prognosis difficult,” Wallace and Wladkowski wrote in Health Affairs. “Patients with chronic illnesses encompass more than half of hospice cases and are more likely to experience a live discharge compared to patients with cancer.”

Live discharges are disruptive to patients and families and could mean that terminally ill individuals do not receive adequate care at the end of life, according to the two authors, who argue that these incidents are critical care transitions that contribute to increased hospitalizations and emergency department visits.

“Although a discharge due to stabilization or lack of decline might sound like a positive outcome — and is often presented as such by hospice teams — most individuals are left struggling to replicate the supportive services that hospice provided — medication delivery, supplies and equipment, access to support around the clock, and routine visits with interprofessional team members,” the authors wrote. “When these services cannot be replicated, patients and caregivers are left to deal with the loss of these services, citing experiences of grief and abandonment.”