Appropriate deprescribing and payment in hospice dementia care

Appropriate deprescribing and payment in hospice dementia care
JAMA Internal Medicine; by Nathan M. Stall, Sharon K. Inouye, Lona Mody; 3/25
People living with dementia are one of the largest growing users of hospice care in the US, with approximately 20% of enrollees having a terminal diagnosis of dementia. In the setting of advanced dementia specifically, guidelines recommend deprescribing cholinesterase inhibitors and memantine as there is insufficient evidence for benefit, and there are risks of adverse events including bradycardia, falls, and gastrointestinal adverse effects. The Centers for Medicare & Medicaid Services specifies that hospices are responsible for covering all medications under the Medicare Part A hospice benefit, but audits have revealed that millions of dollars of prescription drug costs are being inappropriately shifted to Medicare Part D. The study by Hunt et al occurs within a context of growing concerns about shifts in US hospice care where more than 70% of hospice agencies serving patients with terminal illness across all settings now operate on a for-profit basis, with increasing acquisition of hospices by private equity firms and publicly traded corporations. Compared with nonprofit hospices, for-profit hospices have more acute care utilization, provide less direct care, and have poorer caregiver-reported care experiences. For-profit hospices also enroll a higher proportion of persons living with dementia, which may relate to their lower acuity and longer stays, as well as more profitable margins under the per-beneficiary daily payment.