Making the Case for Addressing Health Disparities: What Drives Providers and Payers?

Abstract Purpose: The creation of the Centers for Medicare & Medicaid Services Office of Minority Health placed increased emphasis on federal efforts to address health disparities. Although the literature establishes a social justice case for addressing health disparities, there is limited evidence of this case being sufficient for businesses to invest in such initiatives. The purpose of this study was to better understand the “business case” behind an organization's investment in health disparity reduction work. Methods: We conducted six case studies (44 on-site interviews) with diverse private-sector provider and payer organizations. Results: While providers and payers cited business rationales for initiating disparity-focused efforts, their motivations differed. Conclusion: As federal entities address health disparities, and payment models shift from volume to value, engaging private stakeholders with the leverage to move the health disparities needle is of principal importance. Published in Health EquityVol. 2, No....

Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps?

Abstract Context The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year. Objective The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases. Methods We analyzed monthly hospice outcomes using 2012–2013 Medicare claims. Results Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges. Conclusion Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care. Do Live Discharge Rates Increase as Hospices Approach Their Medicare Aggregate Payment Caps? Dolin, Rachel et al. Journal of Pain and Symptom Management , Volume 55 , Issue 3 , 775 -...

Nearly 1 In 5 Hospice Patients Discharged While Still Alive

Heard on Morning Edition Hospice care is for the dying. It helps patients manage pain so they can focus on spending their remaining time with loved ones. But in recent years, nearly 1 in 5 patients has been discharged from hospice before he or she dies, according to government reports. A study published last month in the journal Health Affairs finds that hospices with the highest rate of so-called live discharges also have the highest profits. The lead author is Rachel Dolin, a David A. Winston fellow researching health policy. Her paper found an association between high live discharge rates and high profit margins, but it didn't determine the cause.... Full article at...

A Positive Association Between Hospice Profit Margin And The Rate At Which Patients Are Discharged Before Death

By Rachel Dolin1, G. Mark Holmes2, Sally C. Stearns3, Denise A. Kirk4, Laura C. Hanson5, Donald H. Taylor6, and Pam Silberman7  Abstract Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death—a practice known as “live discharge.” Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices’ desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012–13 and cost reports for 2011–13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program. Published in Health Affairs, Vol.  36, No....

Factors Driving Live Discharge From Hospice: Provider Perspectives

Abstract Context The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients. Objective The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program. Methods We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach. Results Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices. Conclusion This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate.   Factors Driving Live Discharge From Hospice: Provider Perspectives Dolin, Rachel et al. Journal of Pain and Symptom Management , Volume 53 , Issue 6 , 1050 -...