Health Affairs The United States Hospices ' Enrollment Policies May Contribute To Underuse Of Hospice Care In and

Hospice use in the United States is growing, but little is known about barriers that terminally ill patients may face when trying to access hospice care. This article reports the results of the first national survey of the enrollment policies of 591 US hospices. The survey revealed that 78 percent of hospices had at least one enrollment policy that may restrict access to care for patients with potentially high-cost medical care needs, such as chemotherapy or total parenteral nutrition. Smaller hospices, for-profit hospices, and hospices in certain regions of the country consistently reported more limited enrollment policies. We observe that hospice providers’ own enrollment decisions may be an important contributor to previously observed underuse of hospice by patients and families. Policy changes that should be considered include increasing the Medicare hospice per diem rate for patients with complex needs, which could enable more hospices to expand enrollment. H ospice is a model of health care consistent with the country’s stated health care reform goals: It is patient centered; it uses a multidisciplinary care team; it is coordinated across settings; it reduces unnecessary hospitalizations; and it saves health care dollars. Hospice care in the United States is growing. In 2010 there were more than 3,500 hospice providers—an increase of 53 percent from 2000—caring for 1.1 million Medicare beneficiaries at a cost of $13billion.Ninety-eightpercent of the US population live close enough to a hospice to receive care. Despite this growth, more than half of patients who are eligible and appropriate for hospice care die without receiving it. Several barriers may prevent terminally ill patients fromreceiving thebenefits ofhospice care. Many consider the primary barrier to be the eligibility criteria of Medicare’s hospice benefit, which requires patients to forgo curative care in order to qualify for Medicare coverage. Little is known, however, about the extent to which hospice providers have their own restrictive enrollment practices, over and above the Medicare hospice benefit eligibility criteria. Existing evidenceonhospice enrollmentpractices is sparse, with only one state-level study of hospices in California. That 2000 study found that 63 percent of hospices voluntarily restricted enrollment based on at least one criterion in addition to theMedicare hospice benefit eligibility criteria, and almost one-third had three or four restrictive enrollment policies. There have been no national studies reporting hospice enrollment practices, although such data may be useful for understanding a potentially important reason for the underuse of hospice. This article examines national trends in hospice enrollment practices. It reports the results of the first national survey of hospice providers regarding their enrollment practices. We examined the proportion of hospices that restrict enrollment based on criteria related to the clinical, social, and financial needs of patients. We also determined how enrollment practices differ by doi: 10.1377/hlthaff.2012.0286