Among older adults with dementia enrolled in hospice, rates of overall disenrollment changed minimally from 2012 to 2019. However, disenrollment due to extended prognosis decreased following the implementation of policies targeting long-stay patients, and transfers to another hospice and moves out of service areas increased across the study period.
METHODOLOGY
- Researchers conducted a serial cross-sectional study analyzing data of more than 1.4 million Medicare beneficiaries (mean age, 86 years; 66% women) who were admitted to hospice with dementia as their qualifying terminal condition from 2010 onward and discharged between September 2012 and December 2019.
- They examined disenrollment from hospice, which was defined as the percentage of beneficiaries discharged alive among all discharges that month. Disenrollment was categorized by reported reasons such as extended prognosis, transfer to another hospice, moves out of the service area, discharge for cause, and revocation.
- Disenrollment was further stratified by hospice ownership (for-profit vs nonprofit hospice).
- The analysis spanned the implementation of the 2014 Improving Medicare Post-Acute Care Transformation Act and the 2016 Hospice Payment Reform.
TAKEAWAY
- Between September 2012 and December 2019, rates of overall disenrollment decreased slightly from 24.0% to 23.2%. For-profit hospices had higher rates of overall disenrollment than nonprofit hospices, with rates of 30.5% vs 18.3% by December 2019.
- Disenrollment due to extended prognosis declined from 10.9% (95% CI, 10.7%-11.2%) in September 2012 to 9.7% (95% CI, 9.3%-9.8%) in December 2019.
- Transfers to another hospice increased from 2.6% to 4.0% and moves out of the service area increased from 0.7% to 1.5% across the study period.
- Hospitalization within 3 days occurred in 44.6% of older adults with dementia whose disenrollment was attributed to moves outside the service area, with higher rates of inpatient hospitalizations seen among those in for-profit hospices than among those in nonprofit hospices (47.6% vs 37.8%).
IN PRACTICE
"[The] findings show the importance of disaggregating disenrollment by type. We found decreases in disenrollment due to extended prognosis after federal policy implementation among hospice patients with dementia, but decreases were partially offset by increases in transfers and moves, particularly in for-profit hospices," the authors wrote.
SOURCE
The study was led by Lauren J. Hunt of the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. It was published online on September 15 in the Journal of the American Geriatrics Society.
LIMITATIONS
Dementia was identified through principal hospice diagnoses from claims, which may have evolved with regulatory and auditing changes, potentially affecting trends. Reasons for disenrollment were based on reported codes, which are not routinely audited, potentially leading to misclassification and incomplete representation of actual care transition circumstances.
DISCLOSURES
The study was supported by grants from the National Institutes of Health. The authors reported having no relevant conflicts of interest.
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