Hospice characteristics and the disenrollment of patients with cancer.

Approximately 10–15 percent of individuals with serious illness who enroll in the Medicare Hospice Benefit (MHB) subsequently disenroll from hospice before death (Casarett, Marenberg, and Karlawish 2001; Carlson et al. 2008b; Taylor et al. 2008;). Disenrollment has been shown to be associated with greater likelihoods of hospitalization, emergency department use, intensive care unit admission, and hospital death (Carlson et al. 2008b). Patients who disenroll from hospice are almost five times more expensive to the Medicare program, on average, than those who remain with hospice until death (Carlson et al. 2008b). In addition, hospice disenrollment may be a marker for poor quality care and may limit access to interdisciplinary palliative care services at the end of life for patients and families. Despite these concerns about individuals who disenroll from hospice, we know little about the hospice-level variation in disenrollment rates and the types of hospices with higher disenrollment rates. Hospice disenrollment may be initiated either by the patient or the hospice. Patients may revoke their election of hospice due to dissatisfaction with hospice care, a change in preferences for hospice care, or the desire to pursue treatments not covered under the MHB (e.g., radiation or chemotherapy). A hospice may discharge a patient if the hospice determines that the patient is no longer eligible for hospice care (i.e., terminally ill, defined as having a life expectancy of 6 months or less), the patient moves out of the hospice's service area, or the patient is admitted to a hospital that does not have a hospice contract. Previous studies, which have focused exclusively on patient-level factors associated with disenrollment, have identified younger age (Casarett, Marenberg, and Karlawish 2001; Johnson et al. 2008;), nonwhite race (Johnson et al. 2008), male gender (Casarett, Marenberg, and Karlawish 2001), and noncancer diagnosis (Casarett, Marenberg, and Karlawish 2001; Johnson et al. 2008;) as associated with hospice disenrollment. However, we could find no previous studies that have examined the characteristics of the hospice or of the market in which the hospice operates that might be associated with higher disenrollment rates. Evaluating hospice-level characteristics associated with disenrollment may provide key insights into the system of care for hospice services in the United States. We hypothesize that higher disenrollment rates for some types of hospices, including those that are less established, smaller, or lacking a full range of multidisciplinary staff, may indicate a lack of resources or inadequate care processes to manage the increasingly complex patient population served by hospice. Higher disenrollment rates for some hospices might also indicate variation in patients' and families' understanding of hospices before enrollment. We hypothesize that for-profit hospices may have higher disenrollment rates given that they have been found to provide a narrower range of hospice services to patients (Carlson, Gallo, and Bradley 2004). We also anticipate that hospices in more competitive markets or in urban areas may have higher rates of disenrollment because patients in these markets may be better able to switch to another hospice or palliative care provider if they are not satisfied with their care. Variation in disenrollment rates across hospice fiscal intermediaries might indicate variation in fiscal intermediaries' interpretation or enforcement of hospice eligibility criteria. For instance, fiscal intermediaries, who oversee hospices on a contract basis for the Centers for Medicare and Medicaid Services (CMS), may provide different guidance or incentives to hospices for adhering to eligibility criteria. We hypothesize that hospice-level features are significantly associated with the patient disenrollment. Accordingly, we examined hospice-level variation in disenrollment rates in a national sample of hospice agencies and the association between characteristics of hospices (i.e., age since Medicare certification, size, ownership, staffing, market competitiveness, urban/rural location, fiscal intermediary, and region) and hospice disenrollment. Identifying the types of hospice agencies with higher disenrollment rates is critical in addressing potential organizational-level barriers to having patients and families remain with hospice care continuously until death.