Hospice care for Medicaid cancer patients in Puerto Rico: implications on healthcare costs and utilization.

BACKGROUND: Hospice services play an important role in end-of-life (EoL) care. In Puerto Rico, Medicaid had no provisions for hospice care until July 2024, representing a significant public health challenge. This study examined the association between hospice coverage policy and EoL outcomes among patients with cancer enrolled in Medicaid. METHODS: This population-based retrospective cohort study analyzed data of cancer patients enrolled in Medicaid from the Puerto Rico Central Cancer Registry between 2011 and 2022 who died of cancer between 2016 and 2022. Hospice enrollment was categorized into timeframes before death: 1-7, 8-14, 15-30, 31-90, 91-120, and 121-180 days. We compared total costs, healthcare utilization, and death in acute settings by hospice enrollment status. RESULTS: Of 4481 patients in the study, 21.7% were enrolled in hospice. Non-hospice-enrolled patients had higher healthcare expenditures for the last 7 ($548; 95% confidence interval [CI ]= $166 to $931), 14 ($1619; 95% CI = $894 to $2344), 30 ($3410; 95% CI = $2263 to $4557), 90 ($4896; 95% CI = $1987 to $7804), 120 ($6171; 95% CI = $61 to $12 281), and 180 ($19 291; 95% CI = $10 851 to $27 731) days than hospice-enrolled patients. Emergency department visit rates and hospitalization rates were higher for all periods (P < .05) for non-hospice-enrolled patients than for hospice-enrolled patients. Similarly, non-hospice-enrolled patients had a higher likelihood of dying in acute settings (P < .05). CONCLUSION: Hospice enrollment among Medicaid enrollees was associated with lower health expenditure, lower healthcare resource utilization, and a lower likelihood of mortality in an acute setting. The recent policy change to include hospice services coverage in Puerto Rico Medicaid is a positive step that must be sustained beyond 2027.