Policy issues related to the six-month prognostic standard for eligibility in the Medicare Hospice Benefit

The Medicare Hospice Benefit (MHB) provides financial support to certified hospices for care provided to eligible patients. A patient is eligible to enroll if his physician certifies that the patient has a medical prognosis such that “the individual's life expectancy is 6 months or less if the illness runs its normal course.” There are numerous issues with this definition of eligibility, since prognosis setting is more of an art than a science. This research reviews the legal and scientific literature to describe: (1) the MHB history, its intended purpose, and the regulations governing its implementation; (2) the current understanding of the effects of attempted prognostication; and (3) the issues related to the six-month time window as a MHB eligibility criterion. When Congress passed the MHB, the 6-month prognostic standard was fairly arbitrary, but it has led to significant issues of implementation, ethics and cost. The use of a prognostic standard distorts the case-mix of patients enrolled in hospice and results in under-utilization. The 6-month eligibility standard has a strong adverse effect on 4 groups of patients: those who may be harmed by being told of their prognosis, those with a terminal prognosis of longer than 6 months, those whose medical state leads to difficulty in determining any prognosis, and those whose doctors are uncomfortable communicating a specific prognosis to their patients. Given the arbitrary choice of a 6-month prognostic standard, and the concerns about how the standard affects quality of care and cost, a better eligibility criterion should be determined.