Hospice Characteristics and the Disenrollment of Patients with Cancer

Abstract

Objective. To characterize the types of hospices with higher rates of patient disenrollment from the Medicare Hospice Benefit and the markets in which these hospices operate. Data Source. Secondary analyses of Surveillance, Epidemiology and End Results‐Medicare data. Analyses included patients who died of cancer from 1998 to 2002 and who used hospice (n=90,826). Study Design. We used generalized estimating equations to estimate the association of patient disenrollment with hospice size, years since Medicare certification, ownership, staff mix, competition, urban/rural status, region, and fiscal intermediary. Other covariates included patient demographic and clinical characteristics. Principal Findings. Patients were more likely to disenroll from hospice if they were served by newer hospices (OR=1.14; 95 percent CI 1.03, 1.26), by smaller hospices (OR=1.11; 95 percent CI 1.02, 1.20), or by hospices in more competitive markets (OR=1.17; 95 percent CI 1.03, 1.35). There was an independent effect of the hospice's fiscal intermediary on disenrollment, particularly disenrollment after 6 months with hospice (Wald χ²=21.2, p=.007). Conclusions. The reasons for higher disenrollment rates for newer hospices, for smaller hospices, and for hospices in highly competitive markets are likely complex; however, results suggest that there are organizational‐level barriers to keeping patients with cancer enrolled with hospice. Variation across fiscal intermediaries may indicate that regulatory oversight, particularly of long‐stay patients, influences hospice disenrollment.