Hospice Underutilization in the U.S.: The Misalignment of Regulatory Policy and Clinical Reality

After three and a half decades of experience with the Medicare hospice benefit in the U.S., despite excellent quality outcomes in symptom management, patient and family satisfaction, and reduction in health care costs, only 12%-15% of beneficiaries' days during the last year of life are spent being cared for within the highly cost-effective interdisciplinary coordinated advanced illness care model known as hospice. Although there are many reasons for this, including difficulties in acknowledging mortality among patients, their families, and physicians, a significant cause of low overall hospice utilization and intractably low median lengths of stay, reflective of late admissions, can be attributed to increasingly difficult and highly variable prognostic determinations for most of the leading causes of death among Medicare beneficiaries. Medicare is the payer for most hospice care in the U.S. and requires certification of a prognosis of six months or less for a beneficiary to access hospice support. At the time of admission to hospice, two physicians must predict that a patient is more likely to die in the next six months than survive, based on clinical status. In addition to prognostic uncertainty constituting a barrier to timely hospice referral, the Centers for Medicare and Medicaid Services and its payer contractors have developed a robust and expensive retrospective review process that penalizes hospices when patients outlive their expected prognosis. The administratively burdensome and financially punitive review practices further delay or limit access to care for eligible patients as certifying physicians and agencies, fearful of the financial and legal repercussions of reviews and audits, are hesitant to take patients under care unless they are clearly in the dying process. This article will review pertinent history and address the core problem of access to a health care benefit built on a policy that requires far greater prognostic certainty than any clinician can reasonably ascertain and fails to take into consideration the favorable impact hospice care has on terminally ill patients in improving prognosis. This clinical conundrum that limits access of seriously ill people to high-value quality care is of profound importance to the U.S. Medicare population and also one with potential relevance to all complex and regulated health systems and to other models of care whose eligibility criteria are based on prognostication.