Plan on shipping dear old Mom or Dad off to a hospice one day? You might want to reconsider. A report by the Department of Health and Human Services (HHS) published last August found that many hospice patients aren’t getting the medical care and attention they paid for.
Industry leaders are calling conditions described in the HHS report “repellent” – and are promising a major overhaul. But conservative critics say the current Medicare system is inherently corrupt – and more privatization is needed.
Hospices have grown by 43% in the last decade alone, a reflection of an ongoing shift in the way families treat the death of loved ones as well as the growing share of the Medicare budget devoted to end-of-life care.
The numbers tell the story. Hospice patients increased by 53% between 2006 and 2016. Spending increased even faster — by 83% — over the same period. In other words, hospice services are growing but they’re also becoming more expensive.
But the quality of care may not be improving. Instead, the HHS report found egregious examples of fraud and abuse that left many patients facing substandard treatment.
Some patients were being charged for services they never received; others were receiving services – like morphine injections – they didn’t need. The reason? It allowed hospices to charge the government more.
The report also uncovered evidence – largely anecdotal – that some patients had been left to languish in pain for days on end – sometime weeks. In some extreme cases, patients were being billed for hospice care – and placed in a hospice – that were not even terminally ill.
The office of the Inspector General (IG) has made recommendations to the Centers for Medicare and Medicaid Services, which runs Medicare, in seven key areas, to improve hospice care. Some of these recommendations are so commonsensical one wonders why they weren’t part of the hospice budget to begin with.
For example, the IG has suggested tying hospice care reimbursements to the type and quality of a hospice’s services, rather than the current approach of paying a flat rate. The current system has a tendency to create incentives to minimize services and seek patients with uncomplicated needs.
Another obvious reform is to allow hospice seekers and their families to shop online to compare hospice facilities much as they do in the case of nursing homes. Increased transparency would likely increase the quality of care as hospices scramble and compete to attract new patients, the IG found.
The IG has also recommended that families be shown how to review the summary notices they receive from Medicare detailing their hospice billings. More streamlined reporting would allow families to flag suspicious, unauthorized or blatantly fraudulent services, the office argued.
HHS isn’t waiting for the industry to respond. Last month, it released a second study tthat attempts to quantify some of the problems uncovered in its first report.
Citing data from the 2012-2016, HHS found that one-third of all hospices that provided care to Medicare beneficiaries had received complaints about their services Upon investigation, HHS found that in 2016 over 300 hospices – nearly 20% — had been cited for at least one serious deficiency or at least one substantiated “severe” complaint. Some of these hospices – designated as “poor performers” by HHS — had a history of serious deficiencies that had never been remedied.
While HHS continues to recommend a tightening of reporting requirements and increased monitoring of poor performers, conservative critics argue that these measures aren’t enough. Many would like to see hospice care privatized still further, suggesting that Medicare regulations actually encourage fraud and abuse.
They’re right — in part — but also dead wrong. The problem is that most Medicare-driven corruption is found in the for- profit hospice sector, which accounts for 61% of all hospices nationwide. During the past decade, as the non-profit hospice sector has flat-lined private hospice care has grown substantially.
And the nature of Medicare allows these for-profit hospices to exploit the system to achieve higher profits, regardless of its impact on patient care.
For example, for-profit hospices are much more likely to feature and encourage long-term patient stays (105 compared to 68 days, on average) while also encouraging live short-term discharges that provide a bare-minimum of care are cheaper cost-wise.
According to HHS, these discharges – a violation of HHS guidelines requiring a minimum of 6-month life-expectancy for admission — suggest that for-profit hospices may have inappropriately enrolled some hospice patients to begin with.
Another problem is that for-profit agencies, for all their additional expense, are less likely than not-for-profit agencies to provide discretionary services to their patients.
To be sure, not-for-profit agencies also work on a business model and still pursue a bottom line but there is pursuit is less aggressive – and egregious. Ultimately, the Medicare system for hospice – as in so many other areas – needs a thorough overhaul.
But with so many incentives for fraud and abuse and a resistant bureaucracy, is real reform possible?
Despite urgent calls for change, U.S. hospice care is still “buyer beware.”