A Mixed-Methods Study of the Implications of Medicare Hospice Policy Changes on Patient Utilization and Provider Behaviors
Open AccessHospice is a covered Medicare benefit for beneficiaries with a six-month or shorter prognosis. In October 2014, the Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of hospices with high proportions of long-stay patients (>180 days). In January 2016, Medicare introduced a two-tiered reimbursement system that reduces the daily rate after the first 60 days of a patient’s stay. Both policies aimed to disincentivize provider practices favoring previously more profitable long-stay patients, such as those with Alzheimer’s disease and related dementias (ADRD), whose lengthy and variable end-of-life trajectories make prognostication particularly challenging. The goal of this dissertation was to evaluate patient utilization outcomes and provider behaviors associated with the IMPACT Act and two-tier payment system. First, I leveraged 2008-2019 Medicare claims data to examine trends in ADRD hospice patient share, as well as trends in live discharges and length-of-stay across different patient groups over time and in relation to the policies. Next, I conducted and analyzed semi-structured interviews with hospice industry leaders to understand their perspectives on the policies’ implications for providers and patients, as well as the appropriateness of and alternatives to the current hospice benefit. Overall, findings suggest that policies were associated with reductions in ADRD hospice patient share, and a relative increase in live discharges across all diagnoses, with more pronounced effects in for-profit hospices. Hospices primarily responded to the IMPACT Act through strengthening adherence to hospice eligibility guidelines and patient eligibility documentation efforts, which were noted by interview participants to result in delayed/missed admissions and increased live discharges, particularly for hard-to-prognosticate patients. However, there was no indication from participants of any financially-motivated responses to the two-tier payment system. Notably, despite evidence of increased restrictions in access, there was no corresponding reduction in patient length-of-stay, which instead rose at faster rates after implementation of the policies. Finally, industry leaders generally considered regulations around length-of-stay to be detrimental to patient end-of-life care quality and burdensome to providers, with little effect on fraud deterrence. With a rapidly growing number of chronically-ill older adults, it is vital to investigate and consider alternative cost-effective and patient-centered approaches to end-of-life care.
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Gianattasio_gwu_0075A_16107.pdf | 2022-10-04 | Open Access |
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