Disparities In Hospice Access For Patients With Costly Or Complex Illnesses

1.Identify patient-level barriers to hospice access.2.Describe financial constraints faced by hospice organizations that may result in inequitable access to hospice care. Many hospices have enrollment policies that restrict access for patients with diseases that require expensive treatments and have less predictable trajectories. Patients with two such diseases, heart failure (HF) and cystic fibrosis (CF), may experience inequities in end-of-life care; yet, no research exists regarding the specific patient-level factors that drive hospice agency decision-making. To investigate if medication cost, complexity of disease, and/or diagnosis is associated with hospice willingness to accept patients. Online survey consisting of six patient profiles: “high-cost, high-complexity,” “low-cost, high-complexity,” and “low-cost, low-complexity” for both HF and CF. Each profile included demographics, medical history, prognosis, goals of care, and medications with costs. Individuals involved in hospice decisions (recruited via AAHPM, HPNA, NHPCO listservs, and Twitter advertising) were randomized to view one profile and asked the likelihood of accepting that patient to hospice at their organization, along with questions regarding barriers. Bivariate tests were used to determine associations between various demographic, clinical, and organizational factors and likelihood of acceptance. N=502. The likelihoods of acceptance in CF were: 79.8% (high-cost, high-complexity, n=77), 92.3% (low-cost, high-complexity, n=77), and 91.6% (low-cost, low-complexity, n=85). The likelihoods of acceptance in HF were: 65.6% (high-cost, high-complexity, n=78), 87.4% (low-cost, high-complexity, n=90), and 96.7% (low-cost, low-complexity, n=87). For both HF and CF, respondents were less likely to accept the high-cost, high-complexity patient than the low-cost, high-complexity patient (both p<0.001). For HF, respondents were significantly less likely to accept the low-cost, high-complexity patient than the low-cost, low-complexity patient (p=0.004); for CF, there was no significant difference between the likelihood to accept the two low-cost patients. Treatment cost was the most common barrier to acceptance for four of the six patient profiles. Patients receiving expensive and/or complex treatments for palliation may have difficulty accessing hospice care.