The problem of hospice in nursing homes

As I point out in The Medical Profession Is Dead and the Doctor Is “Critically Ill!“, more factions are able to charge for and be reimbursed for healthcare delivery than ever before. This has come about through creating boutique health care niches. The demand for boutique care is being driven by entrepreneurial interests, and, once brought to fruition, then being managed with corporation business tactics — i.e., for profit.

One of the most incredible niches of them all has been hospice’s success at making care of the dying a specialty niche.  In days of yore, the dying patient’s family physician accepted the responsibility of pain management, comfort and dignity for their dying patients — and took that responsibility quite seriously. Has Medicare bothered to check recently the amount of money they are paying out to hospice for assurance that dying is being managed correctly? The work horses being remunerated for staffing most of these niches are RNs and ARNPs, with a physician, usually somewhere in the distant background, getting a cut of the action, for his supervisory service.

Could a professionally run, altruistic hospice service, for bonafide patients still residing in their own homes, be valuable to the system?

Absolutely. But permitting hospices to enterprisingly ply their trade in nursing homes, where Medicare is already being charged by that facility’s attending physicians — and where nursing salaries are implicitly paid by Medicare as well — is ludicrous.  The nursing homes where end-of-life care is being mismanaged should revoke the privileges of the offending physicians, and nursing homes, whose own administrative policies are resulting in self-serving case management decisions, should lose their Medicare certification.  We must demand quality of care from those being paid to provide it.

It may already be too late for Medicare, but if any hope still remains for its survival, Medicare must begin paring down the numbers of  “providers,” and para-medical consultant services that are currently able to submit charges to them — particularly those submitting charges for poor services, no services, etc. — and physician and facility self-serving services.  Should the current trend continue, soon Medicare will be paying individual nursing homes for only providing an administration and a physical plant for housing the patients.  All other patient care services will be subcontracted out to providers who also will then bill Medicare for their own particular boutique service.

In the nursing homes, hospice care should be the responsibility of the attending physicians and nurses already being remunerated by Medicare for caring for their patients.  Anything else constitutes double dipping.

Alan Cato is the author of The Medical Profession Is Dead and the Doctor Is “Critically Ill!”

Submit a guest post and be heard on social media’s leading physician voice.

Comments are moderated before they are published. Please read the comment policy.

  • http://www.practitionersolutions.com Niamh van Meines

    It would be great if nursing home staff had specialist level of expertise in end of life care. The nursing home regulations result in a rehabilitation effort for patients that have little realistic expectation of recovery, however, it is the nursing home staff that decide that rehabilitation is the order of the day despite their patients having a terminal illness and poor prognosis. Hospices have an uphill battle to gain access and assume professional management in nursing homes. If the patient’s are declining in health, it results in increased scrutiny (or at least, the fear of increased scrutiny) for the nursing home yet hospice care is an entitlement that patients have the right to elect. I have not seen true expertise in symptom management and support for patient’s and their families when residents die, so for now…..I would say that the ability to provide hospice care in nursing homes is not that easy for nursing home staff given their approach to patient care.

    • http://pulse.yahoo.com/_BBXGCBQXS7NNBUX7WZJG2M52FM NurseExec

      As a DON in a 120 bed SNF, end of life care is something in which our nurses excel.  It didn’t happen overnight though.  We have a very involved and proactive Medical Director, and an ARNP from another group who wanted to invest in our nurses providing end of life services directly.  Together, they have written protocols, and given inservices to Nursing, Social Services, Therapy (for comfort positioning), Dietary, and the CNAs.  I much prefer our nurses taking care of residents at the end of their lives than strangers.  Many of these nurses and aides have cared for these residents and their families for years, becoming almost a member of the family.  

      Thanks for the discussion.  I’m always interested in what’s going on in other parts of the country.

      • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

        NurseExec, you are absolutely right.  The bond that forms between some CNAs and patients’ families at the end of life is unique.  This bond is what should be capitalized on in providing end-of-life care, rather than having some faceless medicare-milking entity come in in the last 2 or 3 weeks and suggest we use a fentanyl patch or scopolamine or whatever.  a GOOD nursing home will excel in palliative care WITHOUT the input of a bunch of strangers, as long as the right leadership is in place.  Even without financial incentives like those influencing hospice agencies, those caregivers that have seen the patient decline so deliberately, feel for the patient and family, sometimes as if it was their own family, and almost always WANT to give excellent palliative care.  To have a stranger come in for less than an hour a week and pretend to be caring and loving and involved, well that is an insult.

      • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

        NurseExec, you are absolutely right.  The bond that forms between some CNAs and patients’ families at the end of life is unique.  This bond is what should be capitalized on in providing end-of-life care, rather than having some faceless medicare-milking entity come in in the last 2 or 3 weeks and suggest we use a fentanyl patch or scopolamine or whatever.  a GOOD nursing home will excel in palliative care WITHOUT the input of a bunch of strangers, as long as the right leadership is in place.  Even without financial incentives like those influencing hospice agencies, those caregivers that have seen the patient decline so deliberately, feel for the patient and family, sometimes as if it was their own family, and almost always WANT to give excellent palliative care.  To have a stranger come in for less than an hour a week and pretend to be caring and loving and involved, well that is an insult.

      • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

             Your situation is precisely what we need more of.  You are correct that the bond between the nursing staff and patients in skilled care facilities is like that of family.  Indeed, the nursing staff—sometimes by default, sometimes by choice—is the surrogate family. Your approach also fits in nicely with cost of care solutions, as it avoids needless duplication of services.  In fact, this approach is exactly what I  have been advocating, and the reason for my writing the article that generated this discourse, in the first place.  Please refer to the last two paragraphs in my reply to Dr.Scott Irwin, earlier in the thread.  Thanks for your participation and thanks for your good work.  A. Cato MD    

    • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

      You are absolutely spot-on in your assessment of the nursing homes staffs’ paranoia regarding a death within their facility.  As you also correctly point out, it is largely due to irrational regulatory policies that they are having to work under.  Well, here it comes again.  As I say in The Medical Profession is Dead and the Doctor Is “Critically ill!”—
          ‘Not only do nursing staff share incommon the well-intentioned but misguided reasoning of somepatients families, this group also is dealing with the three fears: fear of adverse publicity for the facility, fear of L & R and other regulatory surveyors misunderstanding, and fear of legal repercussions from the ambulance chasing contingent of our legal profession. In fact, over the years I have found concerned families of patients who have maintained contact, and followed their loved one’s decline from meaningful life to physiological life, much more capable of arriving at a decision in the best overall interest of their loved one than caregivers as a whole. Care givers always maintain a degree of defensive paranoia that they will be blamed for something, leading them often to act in their self-interests, rather than the patient’s best interest.’—

         PS  I hope you do read the book, but, while I believe that you will agree with a great many of my premeises and conclusions—I am absolutely certain there are a few you will not.  However, I would be quite heartened if you were 66 & 2/3 % in agreement. Thanks. A. Cato MD

  • http://twitter.com/renee_berry renee berry

    If “hospice care should be the responsibility of the attending physicians” then they should also all complete board certification of hospice and palliative medicine: http://owl.li/5ZMPo Hospice is not “para-medical consultant services” and far more than physician services.

  • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

    Dr. Cato I couldn’t agree more.

    I have been saying this for years, having been working primarily in a large nursing home for several years.  As various hospice agencies have gotten their claws into our terminally ill patients’ medicare, they send a clueless nurse every couple of weeks who disruptively inquires from the staff how the patient is doing, bugs the physician to order a hemoglobin a1c, knows NOTHING about the patients’ symptom control, is unreachable after hours etc.  They exist first and foremost to bill medicare their lump sum fee.  When the patient dies, who is the physician reachable for calling the family and dealing with the funeral home and death certificate? The nursing home doc.  I don’t think i’ve ever even seen a hospice MD at our facility.

    Then about a month after death, a 6-page consultant note finds its way into the chart from a hospice “team” that nobody’s ever met.

    I agree that in some facilities expertise on managing end-of-life symptoms and family expectations is lacking. But the answer is not to allow some faceless entity to bill medicare for such services that they don’t, and really can’t, provide (they cannot even write orders in the nursing home!).  The answer is obviously for medicare to incentive the growth of the very important field of palliative care, and to create CPT codes which acknowledge the time and effort it takes to keep such patients out of expensive and torturous environments like hospitals at the end of life.

    • http://www.practitionersolutions.com Niamh van Meines

      That is so disappointing…not how hospice care is supposed to work. Do you notice any difference between for profit & not-for profit hospice services?

      • http://www.facebook.com/people/Amy-Ziettlow/553632651 Amy Ziettlow

        Thank you Dr. Cato for this insightful article that echoes what the OIG has been saying for over a decade but unfortunately not enforcing!  I have served in non-profit hospices for over a decade and the growth in for-profits has arisen quickly in the last 5 or so years.  Hospice is incredibly gray and the hospice team engages in countless ethical discussions concerning the care plan for each patient–why is palliative radiation appropriate for one patient and not another? Should we do a blood transfusion, and why? How do we teach non-medical laypeople how to perform often complicated tasks for their loved one in their homes?  That no one member of our team was benefiting financially from a patient’s reimbursement or felt pressure from stockholders who were, took one complicating factor out of very difficult and often contentious discussions about what is best for any given patient and family.  I am a firm believer that content follows form, and I think for bedside care to be at its best and most compassionate you need to know that the administration that supports you as a team member keeps the patient as the bottom line.  I do worry that non-profit hospices will soon be extinct, see my article at the HuffPost: http://www.huffingtonpost.com/rev-amy-ziettlow/nonprofit-hospices-on-the_b_819909.html

        • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

          Dear Ms. Ziettlow,

          I am glad that my article resonated well with you and appreciate your kind response.  I did read your article in the Huffington Post and it was touchigly done.  Unlike some others who responded to my article, I think you realize that I am not against the conept of hospice care.  In fact, I am very much in favor of the concept. I am, however, frightened at the proliferation of for-profit hospices, and at the thought of them lining up at the trough of a possibly already mortally wounded Medicaid.  PS While checking out FamilyScholars.org, I noted that you have Southern Ill ties.  I was born and lived in Southern Ill through my sophomore year in high school.  Keep up the good fight.Very Respectfully Yours,  A. Cato MD

      • http://www.facebook.com/profile.php?id=648920514 Faith Halverson-Ramos

        For what it’s worth, I’m a music therapist who works with a for-profit hospice and I am struck by the level of compassion and care that our team provides for our patients. I understand that this may not always be the case with for-profits, but in my experience our team of knowledgeable health care providers (nurses, HHAs, LCSWs, Chaplains, myself) go above and beyond in providing comfort and support to families and their loved ones.

        I guess I’m just lucky. It’s really a shame that there seem to be so many instances where families, or the staff at facilities where patients are living, don’t receive the communication and care needed from the hospice team.

    • http://pulse.yahoo.com/_HW2PF5TEFUQOVMX3FA3PZYJHFI Ralph

      The nursing home’s DON, case management and admnistrator need to become more involved in the care of the residents at that home.  Hospice can work well, but it requires good and clear communication with everyone involved.  Sounds like the bulk of the initial decisions were made in a vacuum.

  • http://www.facebook.com/profile.php?id=614010948 Earl Smith

    It is unfortunate and true that the hospice doctor is hovering too far in the background for most hospice patients, but end-of-life care has historically been a nursing-driven specialty. There is also a shortage of well-trained physician experts in care of the dying. Dr. Cato makes the case that GPs and traditional family medicine docs should be doing the EOL care. By extension of this argument, there should also not be ob-gyn or surgery or pediatrics…  Hospice and Palliative Medicine is a subspecialty of the Federation of American Boards, and like any other field of medicine can be done well, or not.  I hope that as the field of hospice and palliative medicine expands, our aging population will not fear dying with suffering but instead, anticipate that the end of life, i.e. death, will be a natural process with peace and dignity.  

    • Anonymous

      Dear Mr. Smith,

           Thank you for
      taking the time to reply to my article. 
      Although the article centered on Hospice, a major intent of the article
      was how vulnerable Medicaid and Medicare are to an ever expanding list of
      service providers that they are willing to try and keep up with. There is a
      very significant reason (other than aging baby boomers) why health care is a
      growth industry, and why employment opportunities within health care continue
      to abound, even in today’s dismal job market,—because that’s where the money
      is! Taking inflated profits from the medical sector is nothing new.  The only thing new is novel ways for doing
      it.  In the eighties, I suddenly became
      aware that my office was paying nearly four dollars per box for tissues that we
      kept in the exam rooms and waiting room. 
      Subsequently, the office clerk began stopping by a nearby super market
      for them.  In the case of clinical
      services to the patient, however, the lucrative fees being charged are
      ultimately based historically on the fees charged by MDs for clinical
      care.  The latter’s fees have always been
      felt to be pricey by patients (although today electricians, plumbers,
      mechanics, masons, etc. are on a similar level).  The justification for the fees of physicians
      has always been—and rightfully so— based on the emotional and financial expense
      of the ten to fifteen years of formal post high school education necessary for
      effectively, efficiently and safely practicing medicine.  Increasingly today, specific, focal, clinical
      care niches are being selected out and marketed as necessary “special attention” niches.  They are
      then commanding remuneration far out of proportion to the scientific medical
      skills, knowledge and educations of the staff clinicians actually providing the
      service.  Worse yet, frequently the fees
      charged by these individuals and groups are sufficiently high for covering the
      niche’s clerical support and regulatory defensive medicine practice needs— in
      addition to an MD’s fee, for his/her ostensible
      supervision  of the services being
      provided.

           As for your
      reference to Hospice and Palliative Medicine Society certification, I
      categorically know that the medical science educations of all traditionally
      educated and trained primary care specialty physicians is sufficient, indeed,
      more than sufficient, for obtaining said certification.  No, the problem is not insufficient training
      and education of physicians, nor does the answer reside in the creation of even
      more specific, focal and limited-practice sub specialties.  Increasing the varieties and numbers of niche
      subspecialties only assures the physicians occupying them of a less stressful
      practice, limited numbers of patients to be managed and higher pay—while potentially
      depriving the health care system of a much needed commodity—a primary care
      physician specifically trained for effectively, efficiently and economically
      treating large numbers of patients—while triaging those with bonafide needs—and
      directing them to the appropriate level and specialty of care called for.

           As to your inappropriate “by extension”
      remark, in regard to the specialties of Ob-Gyn and Pediatrics, you should know
      that I have a great respect for all the traditional medical specialties and
      have always utilized them appropriately. 
      Duplication of services, however, is part of the health care system’s
      current runaway cost problem.  I have, for
      example, never referred a baby with candida diaper dermatitis to a
      dermatologist or pediatrician—where the office charge will be considerably
      higher.  The dermatologist, the
      pediatrician and the family practice physician, all, are over-educated for
      treating candida dermatitis.  All of
      them, however, having the appropriate medical education credentials, will be capable
      of recognizing the specific cause of the rash, and therefore will order the
      specifically appropriate antimycotic cream for assuring a cure.  They will not be likely to order up a steroid
      cream that, although might make the rash’s appearance improve temporarily, will
      not cure it—as is increasingly occurring today. 
      The latter is more likely to happen where the clinical provider’s
      medical education credentials are insufficient, or where the clinician’s
      medical credentials are excessively superfluous, and focused on only one
      disease or one organ system.  Respectfully, A. Cato MD  

       

  • Anonymous

    One major factual flaw in Dr. Cato’s post: nursing home care is not a covered Medicare benefit.  It is primarily paid by Medicaid, private LTC insurance, or privately by the patient. 

    • Anonymous

      Dear wcmmb,  Thanks for the correction. I believe you are correct.  But still, as regards Medicare and Medicaid
      solvency, the money still comes out of the same pot.  As for the private pay patient, if they are happy, I am happy, but I’m old enough for remembering when they only had to pay for one physician’s care in the nursing home and they seemed well pleased with the service.  Please forgive an old “fogey”. Dr. C.  

      • Anonymous

        Sent from my HTC on the Now Network from Sprint!

        —– Reply message —–

    • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

      you are right about the NURSING care, but medical care, ie. E&M services, is generally paid by medicare part B, who also duplicatively pays the hospice team a lump sum for their “care”.

      don’t get me wrong, i have worked with really excellent hospice nurses in home care, but in the nursing home this is just another example of a specialty learning how to game the medicare reimbursement system.  some patients enrolled in hospice are admitted to our nursing home without a DNR order, and family isn’t even aware they’re in hospice, somebody signed them up in the hospital.  I know DNR is not required (although i don’t quite understand that one) but i think if someone is enrolled they should’ve at least had a discussion of advanced directives.

  • http://twitter.com/ScottIrwinMD Scott A Irwin, MDPhD

    Unfortunately this writer does not understand that hospice care adds services to what nursing homes provide and physician services are usually provided by the patients primary care doctor (or nursing home doctor).  In fact, there is data to suggest that care in nursing homes that have patients in hospice care provide better care than those that don’t, no matter if the care is being provided to a patient on a hospice service or not.

    • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

      when the hospice patient is sob or nauseous or vomiting of having pain or seizure or the family calls and wants to know the status or needs the death certif signed on the weekend, or WHATEVER,  who sees the patient, communicates to the nursing staff the plan, writes the orders, and talks to the family? the nursing home doc.  no hospice md or nurse around. ever.

      • http://www.practitionersolutions.com Niamh van Meines

        I would imagine the reason for some of these issues are that the nursing home and hospice have not created an integrated approach so that both entities are collaborating & working together to deliver the best care to the patient & family. It’s impossible for the hospice team to provide the care if they are not informed until after the fact, have not been asked to provide it & have limited ability to operate effectively within the nursing home. When I was on call, we always offered visits from RN, SW & chaplain at the time of death when the nursing home called. We often called the nursing homes to check on patients, arranged visits evenings and weekends to the patient’s that were symptomatic and often called to see if they needed anything. Your experience is terrible with hospice but I’m thinking it is simply your experience and does not account for experiences that everyone has with hospice in the nursing home setting.

      • Anonymous

            Thanks for the
        supportive input. It was getting lonely out there.  Obviously your experiences resonate genuine
        with me and, for the most part, closely reflect my own experiences.  Just as obviously, there are also many other
        nursing facilities and hospice services throughout the nation that are doing
        good cost effective work.  I have nursing
        and physician colleagues who work in them, so I know that they are out there too. 
        It is, however, the kinds of providers that you refer to, who are taking
        such a toll on Medicaid’s financial resources. 
        The other point I was attempting
        to make is that this is truly crunch time for the survival of Medicaid and
        Medicare funds, as we have known them. 
        CMS and the states’ Medicaid plans must become more selective in their
        providers and more efficient and effective at identifying and eliminating the
        chronic no service, poor service and self-serving providers. This is not the
        time to be adding additional services to the payroll ledger—regardless of how
        desirable or well intentioned the service might seem.  This is the time to begin weeding out the
        wasteful, the inefficient and the ineffective. 
        It is also an ideal time for calling on those already being remunerated
        for coming up with any additional services currently needed.  The concept of hospice care is a valid and
        sound concept, and we should demand a plan for this service be provided by the
        facilities, physicians and staffs already being totally, or in large part,
        supported by Medicaid funds.  I am sorry,
        but the recent sudden proliferation of for-profit hospices, and their presence
        at the door step of a severely financially wounded Medicaid, is frightening to
        me. A. Cato MD    

    • Anonymous

           Dear Dr. Irwin,
      Thank you so much for taking time to weigh in on this discussion.  I have no doubt that the quality of nursing
      home care and the nature and quality of hospice care varies widely across the
      nation.  Although my personal experiences,
      as a physician, have been with several community rural nursing homes and with
      one state run facility, I suspect that similar sized facilities as these are
      responsible for the stewardship of a sizable chunk of state and federal
      Medicaid expenditures throughout the nation. Unfortunately, it has been my
      experience that wasted dollars and poor service has been pervasive in all of
      them.  It also pains me to admit that
      attending physicians—myself included on more occasions than I like to admit—are
      a large part of the problem through self-serving decision making—usually in the
      interest of defensive medicine, but, all too often, simply for
      convenience.  Equally at fault is the
      self-serving facility administration, intent on defensive posturing and with perfecting
      the appearance of the service record within the chart—as opposed to perfecting
      the actual service to the residents. 
      Jaded and cynical, perhaps, but true nonetheless, based on my
      experiences.

           I have no quarrel
      with the concept of hospice care, and, indeed, if righteously administered,
      with quality personnel (ah, there’s that nagging the-devil’s-in-the-detail
      thing again) hospice care would be the best of all possible approaches for the
      care of end-of-life patients—if financial resources were unlimited.  It is sad that
      Medicaid and Medicare’s histories suggest that each new service qualifying for
      their reimbursement—regardless how righteous or well intentioned the
      concept—ends up being prohibitively costly due to intentional fraud, or from eventual diminution
      of services from the individual providers, once both their charges and services
      become rote.  Remember the high hopes
      held that Home Health Care would prove different. 

           As to your
      allegation that I don’t understand the services that hospice provides—above that
      of attending physicians and nursing homes—I must beg to differ.  As a physician, within a decade or so of
      becoming a potential hospice client, I understand perfectly well that physician
      pain management and medical palliative care are only a small part of any
      bonafide hospice’s services offered.  I
      don’t know your age, but, at age sixty-four, I may be even more acutely aware,
      and more appreciative of hospice care’s invaluable non physician services than
      you are.  But the fact remains that
      Medicaid and Medicare dollars are rapidly approaching passenger pigeon status,
      and the real purpose of my article was to suggest extreme prudence before
      buying into any new Medicaid/Medicare reimbursable service—no matter how desirable
      or how well-intended that service might be. 
      The recent proliferation of for-profit hospices has fueled my concern
      even more.

           In my own naïve
      and simplistic manner, I suppose that I am having trouble in seeing the wisdom
      of ignoring the resources that the majority of nursing homes already have in
      place, and are receiving Medicaid dollars for maintaining.  The vast majority of facilities already have
      attending physicians and a nursing staff—and many have excellent social
      services and other ancillary medical, social and spiritual resources available
      as well.  Others could be recruited from
      community resources. The concept of hospice and palliative care is a sound and desirable
      goal, but the question is how to hold its cost in check, or at least prevent its
      cost from being the final nail in Medicaid’s coffin.  I personally would favor utilizing the
      resources already extant in the nursing facilities and providing the facilities
      with a one-time, lump-sum Medicaid payment for expanding and initiating their
      own in-house hospice services. The lump-sum payment should be sufficient for
      utilizing a quality non profit hospice service for the initial first year,
      while the facility transitions into their own in-house hospice team.  Thereafter, Medicaid would be billed for the in-house
      hospice team’s services at a predetermined negotiated rate.  Of course for this to actually work, would
      require doing something extremely odious and non thinkable to most of the
      medical industry,—mandating that each
      facility participate!  An additional
      unpalatable necessity for this plan’s success would include—please forgive the
      oxymoron—an effective, efficient and economical means of oversight, for
      assuring ongoing quality and compliance.

           Well now, if I
      haven’t convinced you of my perspicacity, I hope that I may have at least convinced
      you of my good intentions. Respectfully,
      A. Cato MD     

  • Anonymous

    Dear Ms. Ziettlow,

    Thanks for your interest, and especiallly thanks for your kind reply.  I have read your touching article in the H.P.
    I sense that you understood that I am not against the hospice concept, but frankly, the recent proliferation of for-profit hospice care agency has me spooked.  The image of for-profit hospice care agencies hovering around the door of an already mortally financially wounded Medicare is simply frightening. PS: I grew up in Southern Illinois.  Thanks again.  A. Cato MD  

  • http://www.practitionersolutions.com Niamh van Meines

    This is an excellent discussion & thank you Dr. Cato for writing about it. Here is some more food for thought……

    Here’s what has been validated through research about the impact of hospice & palliative care services on Medicare / Medicaid expenditures & quality of care:

    1. Palliatice care prolongs life for up to 3 months in patient’s with advanced lung cancer versus those receiving standard treatment. There is a cost savings when terminal patients are counseled about treatment options and elect to discontinue futile and costly treatments in favor of palliation of symptoms and a focus on quality of life. The snowball effect is better symptom control (better quality of life) and less need for costly ER visits.

    2. Hospice care improves the quality of care in patient’s with dementia. See link: http://www.nhpco.org/i4a/pages/index.cfm?pageID=6512. I think we can agree that the bulk of terminal dementia patients reside in nursing homes as they approach end of life.

    3. Hospice care saves up to $2309 per beneficiary on average.  See link: http://www.nhpco.org/i4a/pages/index.cfm?pageid=5386

    4. Hospice care saves money in nursing home residents. See link: http://www.ahrq.gov/research/aug08/0808RA16.htm.

    Perhaps there are other areas / policies / procedures in nursing homes where cost savings or improved services can be found. Like many other healthcare organizations, perhaps looking at the percentage of transfers to ER’s for acute care that might be handled by the nursing home or prevented would be the place to start.

  • http://twitter.com/TaraBloom Tara N Bloom

    I can appreciate Dr. Cato’s concerns about costs as well as the ability of the Nursing Home’s staff being able to fulfill the responsibility of end-of-life care. I am also to sad to see he and the other physician’s negative experience with Hospice care in Nursing homes. Our non-profit hospice has an overwhelmingly positive relationship with the SNF’s we work with, though it did not start that way with all of them. We had to build a relationship based on trust and mutual-communication re: every patients’ individualized plan of care.
     
    Also, there is something no one has really mentioned here. That is, the CMS expressly forbids duplication of services between those provided by the Nursing Home and those provided by Hospice. We are very by the book about this! In fact, sometimes, we have to teach the SNF’s that no, we can’t send out CNA’s out on the days yours are supposed to work, and no, we can’t pay for wheelchairs, b/c that should be covered in your rental agreement etc and if we did, it would be considered inducement. I don’t think all Hospices are as careful about this as we are, but we take great lenghts to be in compliance and any good Hospice organization and SNF should do the same. If this is done, there are not duplication of services/costs.
     
    At the end of the day, Hospice and Palliative medicine IS a speciality, and in my view, a very important one. It is great when Primary Care physicans take the time to cover this as part of their practice, but in our market, only some do. And, most would not say they are experts in geriatric, much less end-of-life care. All of our SNF partners are happy to have us work with them in this special time in their beloved patients’ life as they understand our staff offers an area of expertise they generally don’t have. BTW, our nurses ALWAYS pronounce death in SNFs. That’s our policy and I always thought it was regulatory as well – but maybe I’m wrong.
     
    Thank you for starting this important discussion.

  • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

    Dear Ms. Bloom,  I readily admit that my experience with non-profit hospices  is minimal.  Also, I remind you that, as many of my replies will indicate, I  am a firm believer in the approach and concept of hospice care for all end-of-life
    patients. The influence and voice of hospice as a concept is especially needed at this juncture in our health care system’ history since—as I state in The Medical Profession Is Dead and the Doctor Is “Critically ill!”—’That there is an expected and proper time for death, is being
    ignored entirely in our nation’s nursing homes and hospitals.’
        I suppose I am really lamenting the failure of the attending physicians, nursing staff and administrations of nursing homes, already nearly entirely supported by Medicaid,—to provide appropriate attention and services for their end-of-life residents—thereby creating another medical service void for entrepreneurial types (for profit) to batter at the already meager coffers of Medicaid with.  Throughout the health care system, it seems that, rather than demand quality service from the agencies and clinicians being paid to provide it, the system seems content to continue paying the   inadequate providers—while taking on and paying for an additional provider that they hope will do it right.   

  • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

    Dear Ms. Van Meines,  Your reference to hospice care saving cost by cutting down on ER transfers certainly resonates well with me.  In chapters 4 & 5 of The Medical Profession Is Dead and the Doctor Is “Critically ill!”, I specifically address the the cost associated  with mismanagement of care of end-of-life residents in nursing homes.  Sadlly, the blame for this is equally shared by attending physicians, nursing staff, facility administrations and patients’ families—all parties making their decisions based on , usually convenience or defensive medicine for the clinical group—and guilt, or misdirected grief, in the case of the families.  The following is an excerpt that is specifically pertinent to your unwarranted ER transfers reference: —’The third component for addressing the waste and mismanaged care in nursing homes is an efficient mechanism for monitoring for health care providers who persistently order patient interventions based on convenience, risk management and other self-servingagendas, along with an effective mechanism for reining these individuals in. It is reasonable to believe that if the needless, repetitive ping-ponging of nursing home patients back and forth between acute care hospitals emergency rooms, and back to nursing homes repeatedly, in their last days to months of life, could be successfully stopped, Medicare’s financial footing would become firm again and remain sowell into the foreseeable future.’  Thanks again for your interest.  A. Cato MD

    • http://www.practitionersolutions.com Niamh van Meines

      I might have to read your book since you are such a reasonable & thoughtful man!!!!