Penn Medicine Expert Rethinking Medicare Hospice Eligibility Criteria

PHILADELPHIA – When Medicare hospice eligibility criteria expand in 2011 as part of the Affordable Care Act of 2010, efforts to test whether palliative care and aggressive treatment provided concurrently will be judged based on costs. But a new JAMA article by David Casarett, MD, MA, Associate Professor in the Division of Geriatrics at the University of Pennsylvania School of Medicine, argues that the three-year Concurrent Care Demonstration Project should also examine the impact of new eligibility criteria on hospice access, quality and survival improvements.

“As Medicare tests new eligibility criteria, it is important to look beyond cost measures to see if this improves other important factors, so that patients are able to receive the right level of care at the right time,” said Dr. Casarett, who also serves as the national medical director for research and quality for the National Hospice and Palliative Care Organization. “Providing the appropriate level of care for our patients may mean that a combination of curative and palliative treatments is most appropriate.”

Current Medicare hospice eligibility criteria require patients to forgo aggressive treatment and only offer palliative care in the last six months of life. As a result, patients who do not want to stop aggressive treatment cannot receive pain and symptom management until they halt curative treatment attempts.

The JAMA article proposes measuring access in general, and suggests that we should determine whether concurrent care reduces ethnic disparities in hospice use, since research has shown that black patients are more likely to withdraw from hospice care to receive life-sustaining treatment.

The Demonstration Project should also determine whether patients enroll sooner and stay in hospice care longer, according to Dr. Casarett. There is a known delay in hospice care enrollment, as one-third of patients are referred to hospice in the last week of life and 10 percent in the last 24 hours. Any delay in palliative care can result in unmet needs – physical, emotional, spiritual and social – that could have been addressed earlier, from skilled nursing care for pain and symptom management to support services including on-call help, spiritual support, respite care, as well as counseling and bereavement services for loved ones.

“Penn Home Care and Hospice has started to address these unmet needs with our Caring Way program, a program where patients with chronic conditions are cared for by specialized staff who seamlessly provide symptom management during curative treatment and then palliative care once the patient meets current hospice eligibility criteria,” said Betsy Alexander, MS, BSN, RN, OCN, CHPN, director of Penn Wissahickon Hospice. “It is vital that the Demonstration Project show the value of expanding services to provide patients with both curative and palliative therapies, so we can provide the best treatment options for the patient and the family at a particular point in time.”

Ultimately, the new initiative is charged with evaluating costs, but Dr. Casarett says that “any hospice eligibility criteria should be judged on how well measures of access, quality and survival can ensure that the right patients receive the right services at the right time.”



Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the University of Pennsylvania School of Medicine (founded in 1765 as the nation’s first medical school) and the University of Pennsylvania Health System, which together form a $4 billion enterprise. 

Penn’s School of Medicine is currently ranked #2 in U.S. News & World Report‘s survey of research-oriented medical schools and among the top 10 schools for primary care. The School is consistently among the nation’s top recipients of funding from the National Institutes of Health, with $507.6 million awarded in the 2010 fiscal year. 

The University of Pennsylvania Health System’s patient care facilities include: The Hospital of the University of Pennsylvania – recognized as one of the nation’s top 10 hospitals by U.S. News & World Report; Penn Presbyterian Medical Center; and Pennsylvania Hospital – the nation’s first hospital, founded in 1751. Penn Medicine also includes additional patient care facilities and services throughout the Philadelphia region.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2010, Penn Medicine provided $788 million to benefit our community.