Underuse of Hospice Care by Medicaid-Insured Patients With Stage IV Lung Cancer in New York and California

Abstract

Purpose Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare. Patients and Methods Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results–Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use. Results Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients. Conclusion Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.

Multiple Complex Chronic Conditions and Pediatric Hospice Utilization among California Medicaid Beneficiaries, 2007–2010

“…From the literature on MCCCs at end of life, the findings are sparse and inconsistent. Adult researchers have reported no relationship between MCCCs and hospice utilization, 13,14 while others have found a significant decline in the proportion of patients with multiple conditions using hospice care. 15 Initial work examining pediatric MCCCs at end of life has been primarily descriptive and methodological.…”

End-of-Life Care Characteristics for Young Adults with Cancer Who Die in the Hospital

“…[5][6][7][8][9][10] Nonelderly adults are also less likely to receive palliative and/or hospice services prior to death. 6,11 From the pediatric perspective, the majority of children who die from cancer die in the initial treatment phase, in the hospital, in an ICU, while still receiving aggressive curative therapies (e.g., chemotherapy). [12][13][14][15][16][17] Preliminary evidence from adolescents at the end of life suggests that they prefer to die at home, yet the vast majority die in a hospital setting.…”

NCCN Guidelines Insights: Palliative Care, Version 2.2017

“…54,55 Unfortunately, most US patients who receive hospice care are referred too late for hospice care to exert its full benefit, and many patients are never referred at all. 49,53,56 Several groups have examined patterns in referrals to hospice care. A recent study at an academic medical center showed marked and unwarranted variation in hospice LOS within divisions and by doctor.…”