Hospice Use Racial and Ethnic Inequalities Among Medicaid Population

A retrospective cohort study published in JAMA Health Forum reveals racial and ethnic disparities in hospice use and length of stay among Medicaid recipients, highlighting concerns about equity and access to end-of-life care for low-income individuals. 

The COVID-19 pandemic brought attention to disparities in end-of-life care, particularly among different racial and ethnic groups. However, limited data on hospice use outside of Medicare has made it difficult to assess these inequities. Most research on hospice use focuses on Medicare beneficiaries, but little is known about the experiences of racially and ethnically diverse, low-income individuals with Medicaid. 

Researchers designed a retrospective population-based cohort study to compare hospice use and hospice length of stay (LOS) by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. 

The study utilizes Medicaid and traditional Medicare enrollment and claims data from 2015 to 2020. It specifically focuses on Connecticut Medicaid recipients who passed away between 2017 and 2020 and had 1 of the 5 most prevalent hospice diagnoses. The sample was selected from an integrated data set that combined Medicaid enrollment and claims data from the Connecticut Medicaid Management Information System with federal Medicare Part A, B, and D enrollment, and Chronic Conditions Warehouse (CCW) data. 

Researchers specifically analyzed the characteristics of the Medicaid-only and dual populations and the differences between hospice recipients and nonrecipients. It was found that in both populations, a higher percentage of people who received hospice were non-Hispanic White, older, female, and diagnosed with cancer or dementia. The Medicaid-only population was smaller and more racially diverse than the dual population, with a lower proportion of females and a lower frequency of hospice utilization. Additionally, the dual population had a higher likelihood of having multiple qualifying diagnoses and a higher rate of nursing facility stays within 60 days of death.  

In bivariate analysis, race and ethnicity were significantly associated with hospice use and short length of stay for the Medicaid-only population. Non-Hispanic White and Asian decedents had the highest hospice use, while non-Hispanic Black and Hispanic decedents had the lowest. For the dual population, race and ethnicity were only significantly associated with hospice use, with non-Hispanic White individuals receiving hospice at a higher rate than other racial and ethnic categories. Multivariable logistic regression models confirmed these associations and revealed that Hispanic and non-Hispanic Black individuals had lower odds of using hospice compared to non-Hispanic White decedents in both populations. 

“Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals,” said researchers. “Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.” 

Reference  

Robison J, Shugrue N, Dillon E, et al. Racial and ethnic differences in hospice use among Medicaid-only and dual-eligible decedents. JAMA Health Forum. 2023;4(12):e234240. doi:10.1001/jamahealthforum.2023.4240