Hospice at a Crossroads: Policy, Incentives, and the Challenge of Dementia Care
IHPS Health Policy Grand Rounds
The Medicare Hospice Benefit provides interdisciplinary end-of-life care to millions of Americans, but its eligibility, payment, and regulatory structures were developed in a different era and often fit poorly with the long and unpredictable course of dementia. Drs. Lauren Hunt and Krista Harrison will draw on their complementary research programs, combining population-level quantitative evidence with qualitative perspectives from bereaved caregivers and hospice professionals, to examine how hospice policy and organizational incentives shape access, care delivery, disenrollment, disparities, and family experiences. The findings highlight tensions between expanding access to needed care and preventing undertreatment, inappropriate enrollment, and profiteering. Hospice policy must be redesigned to better fit the needs of people with dementia and their families while preserving the benefits of hospice care.
Krista Harrison, PhD, is an interdisciplinary social scientist and former hospice administrator whose work lies at the intersection of health policy, gerontology, and hospice and palliative care. She is an Associate Professor in the UCSF Division of Geriatrics and Philip R. Lee Institute for Health Policy Studies (IHPS). Her research aims to mitigate suffering by improving models of care & policies for older adults living with, dying from, and grieving neurodegenerative diseases and other serious illnesses. She combines qualitative and mixed-methods approaches—including interviews, observations, case studies, and focus groups—with nationally representative survey and Medicare data to understand patient and caregiver needs and inform improvements in hospice, home-, and community-based care. She currently leads the NIH-funded HEARD Study, a five-year study examining experiences and opportunities to improve equity in hospice and end-of-life care for people impacted by dementia, then translating evidence into actionable recommendations for healthcare organizations and policymakers. Dr. Harrison completed her PhD in health policy, health services research and public health ethics at the Johns Hopkins Bloomberg School of Public Health; postdoctoral training in aging research and implementation science at UCSF, and an Atlantic Fellowship for Brain Health at the Global Brain Health Institute. Before joining UCSF, Dr. Harrison was a leader within a large nonprofit community-based hospice and palliative care organization.
Lauren Hunt is a PhD-trained nurse researcher whose work lies at the intersection of geriatrics, hospice and palliative care, and health policy. She holds dual appointments as an Associate Professor in the UCSF Philip R. Lee Institute for Health Policy Studies and the Department of Epidemiology and Biostatistics. She is also a Senior Atlantic Fellow at the UCSF Global Brain Health Institute. The overarching goal of her research program is to generate evidence that informs health policy and care delivery, with the aim of ensuring that all older adults with serious illness, particularly those living with dementia, receive high-quality end-of-life care. Her research has received numerous awards and recognitions from professional societies and has been supported by grants from the National Institutes of Health, the Health Resources and Services Administration (HRSA), and leading private foundations. Most recently, her work has focused on the effects of hospice ownership and market competition on access to high-quality hospice care. Additional areas of her research portfolio include pain and symptom burden, clinical and healthcare utilization trajectories, workforce challenges, and disparities in care and outcomes among older adults with serious illness.