Drivers of Live Discharge from the Medicare Hospice Program: A Mixed Methods Study Public Deposited

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  • March 20, 2019
Creator
  • Dolin, Rachel
    • Affiliation: Gillings School of Global Public Health, Department of Health Policy and Management
Abstract
  • The proportion of Medicare decedents accessing the hospice benefit at the end of life increased by more than 30 percentage points between 2000 and 2013. Yet the share of patients disenrolling from hospice prior to death has steadily increased over the last decade, representing nearly a fifth of all hospice discharges in 2012. Due to variations in the rate of live discharge at the hospice- and market-level, this outcome has come under scrutiny from policymakers, providers, and advocates as a potential indicator of poor quality. Such variations in live discharge rates and their documented association with hospice characteristics suggest that factors beyond patient choice may be driving these trends. The overall objective of this dissertation study was to better understand the factors driving live discharge from hospice. To explore this area of inquiry, I conducted three studies: 1) A qualitative study exploring provider perceptions of the factors driving live discharge from hospices (chapter 2), 2) a quantitative facility-level study analyzing the relationship between hospice margins and live discharge rates (chapter 3), and 3) an empirical work delving into the relationship between the timing of live discharges relative to the hospice aggregate cap (and each hospice’s respective risk of exceeding the cap at different points in the year) and the likelihood of an individual patient’s experiencing a live discharge (chapter 4). Overall, the results from these three studies together paint a complicated picture in which live discharges stem from not one primary driver but the confluence of many factors, arrayed in a variety of ways, to produce each individual patient-level outcome. Although these three studies provide evidence for “gaming” in the hospice delivery system, such trends do not suggest that higher live discharge rates are automatically reflective of poor quality — and vice versa. The Centers for Medicare & Medicaid Services ought to, thus, exercise caution before proceeding with a live discharge claims-based quality indicator. More generally, the totality of this work suggests that the Medicare hospice program has serious issues that must be resolved through payment system reform, increased oversight, benefit redesign, or some combination thereof.
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  • In Copyright
Advisor
  • Silberman, Pam
  • Holmes, George M.
  • Hanson, Laura
  • Stearns, Sally
  • Taylor, Donald
Degree
  • Doctor of Philosophy
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2017
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