Why is Medicare going after hospices?

Seven months ago, in Carbondale, Colorado, staff at the skilled nursing facility where my mother had resided for over a year recommended that she be placed on hospice.  My mother has severe advanced dementia and can no longer walk, speak, feed herself or recognize her family members.

As much as I know about hospice care for cancer patients here in San Diego, I knew nothing about hospice care in Carbondale for severely demented patients.  Although we had declared my mother DNR (“Do Not Resuscitate”) when she entered the nursing facility in January of 2011, my concern was that this meant that once she was transferred to the care of hospice workers, albeit in the same bed in the same facility, she would be left alone in soiled diapers to die.  She could not ask for anything, did not need any medications for pain or otherwise, and did not respond to questions.  I envisioned that hospice had more pressing problems to deal with—for example, cancer patients in severe pain or with debilitating shortness of breath or inconsolable family members. My father was convinced, but I was not.  I could not have been more wrong.

On November 12, the news broke in the San Diego Union Tribune that the San Diego Hospice, a not for profit highly respected hospice in our area, was being audited by Medicare.  The hospice had stopped accepting patients November 10, and there was a threatened layoff of 200 of the 870 employees.  Two programs—one for HIV/AIDS and one for the parents of newborns with life threatening illnesses who were not expected to survive, were halted immediately.  And what crime did the San Diego Hospice commit?  The audit focused on whether the hospice had been “too liberal” in its admissions.  You see, in order to qualify for Medicare hospice benefits, you have to be expected to die within six months.  If you are terminal by this definition, Medicare pays $172 per day for your care.

The thing of it is that all of the patients admitted by the San Diego Hospice did not die on schedule.  The hospice spokeswoman was quoted as saying, “We put the concept of patients and what we were able to do for them above what the guidelines are.”  A day later, both the physician CEO and the CFO resigned.  Ironically, the reason that the hospice is being penalized is perhaps that the care was just too good—that by taking away fear, and providing excellent pain management and emotional support—the patients lived longer than the expected six months.  And there is no comparison “other side of the coin”—what would these patients have cost society if they had continued on active chemotherapy or radiation, or had expensive acute care hospitalizations for infection or pain management?

Medicare has been offering a hospice benefit since 1982.  In 2000, 513,000 patients took advantage of the benefit.  In 2010, 1,100,000 patients went on hospice.  The cost to Medicare was 3 billion in 2000, and 13 billion in 2010.  Do the governing bodies of Medicare truly think that this is because hospices all over America are plotting to defraud the government?  Personally, I think not.  While there is Medicare fraud in all segments of the medical and hospital businesses, I prefer to think that the increase is due to the aging of our population, the acceptance into hospice of more Alzheimer’s and other chronic disease patients, and the growing level of comfort among physicians to consider hospice when there is no chance of a reasonable recovery for their patients. Undeniably, there has been a sharp increase in the number of for profit hospices nationwide, from 34% in 2001 to 55% in 2011, causing alarms to go off and triggering Medicare audits across the country.

A week ago my father called me to say that the nursing facility in Carbondale had no other choice but to take my mother off of hospice.  The volunteers who came in to read to her, despite her lack of response, the massage therapists, the bright smiles and the occasional little gifts of lotion and a flower—are all gone. My mother, because of the excellent care she has received at the nursing home and from the local hospice, had simply failed to die on time of a bedsore, a urinary tract infection, or aspiration pneumonia.  My father is lucky—if he chooses to he can continue some of the services that hospice was providing by paying for them out of pocket.  San Diego Hospice closed the doors of its 24 bed inpatient facility recently.  I wonder if the patients who were being cared for by the wonderful doctors and nurses and staff there will be so lucky.

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries

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  • cynholt

    My only complaint about the hospice industry is that many employed in this industry, mainly the docs, like to think of themselves as almost God-like when it comes to predicting death among the dying. But the sad thing about it is that they score only slightly better than the average Joe Blow off the street at predicting when those who are dying are gonna draw their last breath.

    From my experience in hospice, as opposed to critical care, I’ve
    noticed that for some unexplained reason soon after many patients who are classified as dying or near death get a second wind after being weaned off of life-sustaining things — anything from cardiopulmonary drugs all the way to food and water. For some unexplained reason, living on nothing but opiates coupled with lots of touchy-feely stuff often has a paradoxical effect on the dying, causing them to live far longer than the most wonkish Doctor Death around could have ever predicted.

    But if those employed in hospice, mainly the docs, would view what they do as more of an art than a science, they’d stop putting so much damn weight on predicting death among the dying. Then again, if it’s proven that hospice care isn’t well-grounded in science, then the hospice industry would be at great risk of losing health care dollars from Uncle Sam. Needless to say, when it comes to the amount of available public funds floating around, the arts pale in comparison to
    the sciences. This may explain why hospice docs make it a top priority of theirs to fine-tune their so-called “scientific” skills at predicting death among the dying.

    • Suzi Q 38

      It is probably way too expensive.
      I thought that hospice was only for a few months, at the very end of one’s life.
      If the patient lives past the allotted time, maybe they have to move the patient back into a nursing facility.
      My BIL was dying of cancer but he wanted to go home.
      We just took him home, took shifts, hired nurses, to fill in the gap, and he died within two weeks.

      How can one predict when and if someone will die?

      Once my FIL received his last rites. The hospital staff removed him from the ventilator. Instead of dying, he woke up, started breathing, made eye contact with all of us and mouthed “hello.”

      He lived for 5 years after that. I think his PCP died before he did.

      My MIL received hospice for about 3 weeks at a teaching cancer hospital. She was in so much pain that they kept her sane with morphine until she sadly died.

      If the patient ends up living, shouldn’t they go home with nursing care or go to a private nursing home?

      We had to pay $4K a month for a really good nursing home the last 3 years of his life. The previous 7 years, he lived with us. Nurses came in 3 days a week and he also went to adult day care.

      He looked fairly good until he died.

    • Dorothygreen

      How do hospice doctors “predict death” anyway that upsets you so?. More people probably need hospice earlier than those who recieve it. Isn’t this what the studies show? Isn’t it mostly the case that the primary physician will hesitate to recommend hospice because they think they can either “prolong the patients life” or it would be unsetting etc?. If hospice was mandated to be not for profit just as all essential health care services should be there would probably be no need for even a discussion on this website.

  • margo

    It seems like medicare needs hospice care!!! so so sad!! There is all this real fraud with medicare paying 4 times the amount it should for unnecessary wheelchairs–the scooter store –but then going after a hospice?? so cruel!! And to call it fraud is ridiculous…
    it seems like medicare needs hospice care. It is dying a slow death. When will it ever end?

  • southerndoc1

    I don’t understand why you feel that your mother should receive hospice services from Medicare. What were they providing at $172/day that one wouldn’t expect from the nursing home? Thanks.

    • Miranda Fielding

      What she was receiving was a little extra personal attention, even though she could not reciprocate. She got excellent care in her nursing home, but hospice volunteers read to her, gave her massages– just the little things to add to her comfort. She died last Monday, about a month after being taken off hospice because she outlived her hospice benefits. If you read closely, I was actually opposed to hospice for her because I thought she would get less care, but I was pleasantly surprised.

      • Suzi Q 38

        I am sorry that your mother died, Dr. Fielding.

        • Miranda Fielding

          Thanks Suzi. It was not unexpected, given the circumstances. But losing a parent is never easy.

      • southerndoc1

        Thanks for the reply. But “a little extrapersonal attention” is not what Medicare hospice is intended for. I think it’s pretty clear why this group was audited: they were providing and billing for services that fell outside the regulations.
        Hospice has become a HUGE business, and a huge area of Medicare fraud. Non-profit or not, they have to play by the rules.

        • Miranda Fielding

          Thank you. I just want to make it clear that my mother was not cared for by the San Diego Hospice, which is now undergoing a Medicare audit. I have the utmost respect for the San Diego Hospice since many of my patients are cared for by them when they are terminal. I do get your point of why should my mother be on hospice (in Colorado where she and my Dad lived) when she was in a nursing home. I asked the same question myself when it was proposed–I didn’t see the point. That being said, I do appreciate what they did for her.

      • kjindal

        So sorry for your loss.
        I echo, however, the sentiments of southerndoc. I work primarily in a large urgan nursing home, and when a hospice agency gets their politically-connected claws on a dying patient, they submit a big fat bill to medicare (by your calculations about $13,000 per patient) then provide almost NO tangible services to such patients. In a nursing home, the facility and physicians still bill medicare, while hospice agencies get their big fee, then are unavailable to a) talk to families; b) provide counseling by either social work or clergy; c) provide ANY hands-on nursing care; d) provide ANY in-person physician care or decision-making. When there is a crisis (which is OFTEN with such patients) it is the staff of the nursing home doing all the work. Occasionally a well-meaning nurse will pop by for a few minutes, review the chart (sometimes without even actually seeing the patient), and ask idiotic questions of me like “doctor, what was the last hemoglobin A1c on Ms. Jones”.
        Then finally when the patient dies, the highly paid hospice medical director who contributed nothing to the actual end-of-life care is unavailable to complete & sign a death certificate. Then a few weeks later we get a 6-page beautiful typed “consult” note from him/her detailing the extensive templated recommendations for dealing with terminal signs & symptoms (again, well after said patient died).
        So I, for one, am thrilled that medicare is clamping down on this charade. there absolutely IS rampant fraud in the hospice industry. Many of my Spanish-speaking patients were admitted to the SNF unaware that they were enrolled in hospice in the hospital (and are FULL CODE).

        • Miranda Fielding

          I absolutely agree about one thing: as an oncologist, I have been MUCH happier when my patients signed on to non profit hospices than the for profit ones–I notice a huge difference in services. The San Diego Hospice which I spoke of is a non profit.

        • Dorothygreen

          Curious, is this a not-for profit hospice or for-profit. And also, a nursing home hospice situation is different than a patient’ home. Seems to me something could be worked out such that the hospice gets less for a patient who is cared for in a nursing home. It seems like a lot of redundancy. Volunteers are needed for patients in nursing homes whether on hospice or not.

    • kjindal

      not sure if it’s $172/day or possibly an up-front lump sum payment. The latter would make sense, given that I see a rapid de-escalation of services shortly after enrollment in hospice. This makes it even more expensive for the taxpayer (hospice enrolls patient on day 1, collects $x000, then patient dies on day 5, saving agency their having to pay a nurse, social worker, etc.)

  • http://www.facebook.com/people/Chagai-Dubrawsky/604353306 Chagai Dubrawsky

    Hospice is a place where chronically ill,terminal people are “Shelved’,with expectation of death.
    Not dying in a timely fashion,is frustrating to the establishment,as it cost it a lot of money.
    What would you say if we could slow down the process,and even reverse the trend of immediate demise.Increadible?maybe,but it is worth a try.
    I have an idea in that matter.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Having worked as a volunteer part time medical director of our local hospice in the late 1970′s early 1980′s I was amazed and humbled by the time and effort put in by volunteer lay personnel, nurses, therapists, psychologists, pharmacists all taking training and devoting their time to providing care and comfort and support to the sick and their families. Respite for families was as big a service as anything they did. In the early 1980′s Medicare started funding Hospice. Volunteer workers were left behind. Salaried full time personnel at every level replaced volunteers. With government money comes rules and regulations . Our local hospices as still like angels of mercy but the bureaucracy and rules are overwhelming. With Medicare funds they do reach a greater patient base. Is it worth dealing with the bureaucracy?

    • SBornfeld

      Someone correct me if I’m wrong (and particulars may be different from state to state.
      When my MIL broke her hip (she had cancer), she went into a rehab facility. We were told that Medicare covers for 1 month; then she went into a skilled nursing facility, and she self-paid the rest of her life. If and when the patient’s funds run out Medicaid comes in.
      Most of the nursing homes here are awful; I’d like to think that most hospice facilities are better.
      Nice to hear they sometimes are.
      My sympathies, Dr. Fielding!

      • Miranda Fielding

        Thank you. I am sorry about your own mother in law. My parents took out long term care policies many years ago, and my mother’s paid for her nursing home, or at least a good chunk of it. Buying long term care insurance is on my “to do” list, but it is expensive.

  • Hospice Nurse

    Many people do not understand the Medicare hospice benefit. The hospice is paid a flat rate per day for the level of care being provided. All of the care discussed thus far in these comments has been for what is called “Routine Home Care”. In all levels of care, the hospice is paid a per diem..no lump sum. From that amount, the hospice provides the services of a medical director (doctor), a nurse who is specially trained in symptom management, a medical social worker, a chaplain, a personal care aide, a volunteer, all medical equipment and supplies, including oxygen, hospital beds, BSC, diapers, dressings, catheters, etc. Most nursing homes, in our area, do not get extra staff when they have a dying resident. Hospice provides the extra staff support for routine personal hygiene, medical direction for symptom management, etc. Our staff, including the doctor, visit the patient routinely in the nursing home at least as often as they do those in the private home. Nurses are also available on call 24/7. That means any patient or caregiver can call and expect to receive nursing support 24/7. Volunteers are still very much a part of the hospice team although it is getting harder to find people willing to make that commitment due to the increased expense of travel, so many unemployed, etc. (We are in a rural area in the Mid-west.)

    The cost of hospice has been proven to save Medicare dollars. Six months on hospice costs the taxpayer about the same as 1 week in a hospital. Our average length of stay is 2 weeks. Of course, there will be some who will live more than 6 months. It is true that in many cases, the patient’s condition will improve for a time after all of the “curative treatments” are withheld. This is usually temporary. I have noticed that those cancer patients who have refused treatment are the most difficult to guess life expectancy. It is a guess. Doctors who refer their patients to hospice must certify expected prognosis to be 6 months or less “if the disease process continues as typically does” in that physician’s experience. It is not the hospice medical director who initially directs a patient towards hospice. It is a physician who has much more knowledge of that patient. The patient’s referring physician is given the choice of continuing to manage their patient’s care or asking the hospice medical director to do so. Either way, the PCP remains a part of the patient’s care team unless they chose not to. Only God knows how long anyone will remain on this earth.

    Families who receive the support and encouragement from our hospice team tell us that they should have started hospice sooner and that they could not have done it without us. We know that is not so. What they are really saying, I think, is that we made their last weeks with their loved one a bit easier and it would have been nice to have had such support earlier on. Our goal is to provide comfort and support. That goes to both the patient and the family/facility staff. We empower them to provide the real care and our staff take over only when the task is beyond their capabilities or willingness to do. This is in keeping with the wishes of our patients who want to be at home with the family. Our staff feel blessed to be accepted by so many families at such a difficult time in their lives.

    • Miranda Fielding

      Thank you SO MUCH for taking the time to write. You said it so much better than I ever could. I have the utmost respect for all hospice workers, but especially the nurses. You have a hard job, and you do it well. Thank you.

  • Hospice Nurse

    I forgot to add…Also included in the expenses taken from the per diem paid to the hospice is all of the meds related to the terminal diagnosis and all “comfort” meds.

  • Dorothygreen

    Wow, this entire conversation left me depressed. I hope I never get to the point where I have to go to a nursing home. Hospice, OK as long as I know I am going to die and am able to administer my own pain meds. Otherwise give me the liberty of death. No massages, no reading, nothing that uses taxpayer money or volunteer time to keep me alive. There is so much else in the world to accomplish.
    Please. If my brain is dead or dying – pull the plug. My family understands.

  • meyati

    I read another report about the investigation of the San Diego hospice. It scares the crap out of me. One of the major factors was having adequate pain management at the hospice, which caused patients to sleep better, and be more interested in things, which improved their general health, so they out-lived their 6 month limit. Some how, nursing facilities are told that pain management is too complicated, and patients suffer needlessly. We all know that some cancers prefer to travel and drill through bone. A person isn’t going to die right off from bones being drilled through, but the pain is excruciating. I have a rare form of bone drillers. It started in my nose, so I have 2 options-my lungs fill up and suffocate me in about 8 months: maybe go down my back and drill through my shoulder blades or something-and maybe years of that. Oh, yes, when you cut one tumor out-others pop up- I am so scared of the pain and the DEA, and FDA, and stupid medicare. I’m not scared of dying but I’ve watched people die from cancer and it’s not pleasant.

    • Miranda Fielding

      Perhaps you could be referred to a pain management specialist BEFORE you really need one–it’s good to establish a relationship early on. Also, I want to tell you that radiation therapy is very good at relieving bone pain, in as few as one treatment. Good luck in your fight.

  • Jack

    When ever I do a Medicare ABC& D presentation and get to medicare A Hospice I always say Hospice should be Medicare E.

    It is such a wonderful benefit for not only the patient but for families. They were there for my mom and dad and I will never forget the great service they provided for our family.

    Medicare has it all backwards