Recent changes to the Medicare hospice benefit may adversely impact access to hospice care for terminal Alzheimer?s disease and related dementia (ADRD) patients, who currently make up 16% of all hospice patients and 36% of aged decedents. In 2014, the IMPACT Act introduced stringent hospice auditing procedures targeting long patient stays, and in 2016, Medicare implemented a two-tiered payment schedule reducing hospice reimbursement after 60 days. Both changes aimed to dis-incentivize hospices from selecting for long- stay patients, who were more profitable (and admitted at higher rates to for-profit agencies) than short-stay patients. ADRD patients typically have longer length of stay (LOS) due to their lengthier and less predictable end-of life (EOL) trajectories, and while circumstantial and qualitative evidence suggests that these changes may reduce ADRD patient hospice use, the effect of these policies is currently unknown. Hospice has been recognized as the best way to maintain the high quality of life (QOL) for severely-ill patients, and appears particularly beneficial to EOL ADRD patients given their complex needs. Therefore, decreased access to hospice would adversely impact QOL for ADRD patients and their families. Thus, there is a critical need to understand how these policies affect ADRD patients? use of hospice. Our proposal directly addresses this need. We will determine the extent to which the implementation of the IMPACT Act (Aim 1) and the two-tiered payment schedule (Aim 2) affect (a) hospice admission, (b) hospice LOS, and (c) the rate of live discharges for ADRD patients. Additionally, because for-profit hospice agencies may be more impacted by increased audits and changes in monetary incentives, we propose to examine the extent to which policy effects on these outcomes are different at for-profit versus non-profit agencies (Aim 3). To accomplish these aims, we will use econometric methods to analyze Medicare hospice claims data from 2008 to 2018. This proposed research is a timely and necessary first step to investigate the policy effects on ADRD patient access to and use of hospice. The findings of this research will (i) advance our understanding of how hospice providers respond to regulatory oversight and monetary incentives, and will (ii) inform how policy levers can be used to improve the Medicare hospice benefit in design, implementation, and oversight, in order to maximize the value and quality of EOL care for the ADRD patient population. Our findings will also have a translational impact because other Medicare beneficiaries with ?non-traditional? hospice diagnoses, who also have long and unpredictable EOL trajectories, may be similarly impacted. This proposal represents a first, necessary step in a planned research agenda to improve EOL care for ADRD patients through use of policy and health systems changes.
The proposed research is relevant to efforts to improve end-of-life care for Alzheimer?s Dementia and Related Dementias (ADRD) patients because the quality-of-care and quality-of-life of ADRD patients at the end-of-life hinges importantly on their access to and use of hospice services. As Medicare is the primary payer of hospice services, policy changes affecting the Medicare hospice benefit directly impact ADRD patient use of hospice. Our findings will be used to improve the Medicare hospice benefit in design, implementation, and oversight to maximize the quality and efficiency of care for ADRD patients at the end-of-life, as well as increase support to their families, and will have translational impact when considering other patient populations with long or unpredictable end-of-life trajectories.