A headline in the business section of the Atlanta Journal several weeks ago caught my eye: “Atlanta hospice to pay $3 million.” That’s a lot of cash. The article went on.
“A Georgia hospice company has agreed to pay $3 million to resolve allegations it billed taxpayers for patients who were not terminally ill, the latest such settlement as federal officials target what they call a burgeoning number of abusive hospice schemes.” (italics mine)
There’s no question how important hospice care can be for someone to live their last days fully, surrounded by their loved ones and personal belongings, and supported with the physical, social, and spiritual services that underpin hospice care.
However there’s a darker side to hospice care, one that I experienced when I searched for hospice care for my own family members.
At one point almost all hospice organizations were non-profits, operated by hospitals or visiting nurse programs as an extension and more holistic approach to end of life care. As Medicare and other insurance companies began to extend coverage for hospice care, organizations providing hospice care began to multiply. Four years ago when I embarked on that search for my brother, there were over 100 hospice providers at Atlanta. Over 100!
Medicare or private insurance pay hospice providers a flat daily rate to provide nursing, social services, chaplaincy, and personal care services that comprise hospice care. That daily reimbursement per patient also has to cover any durable medical equipment (a hospital bed, bedside commode, oxygen, medications) that are needed for that care.
Hospice care used to focus on patients with cancer diagnoses almost exclusively. Now any condition which is expected to end with the patient’s death within 6 months, including conditions like congestive heart failure and COPD can qualify for hospice care.
Keep in mind also that hospice is an approach to care, and less commonly a bricks and mortar “place” where that care is provided. The vast majority of hospice care is provided in the patient’s home, with the family or paid professionals providing day to day care. Where facility-based hospice care is offered beyond a few day’s respite, the cost is often higher than the Medicare reimbursement, which has to be paid by the patient or their family.
As important a choice as hospice care can be, in this country, patients often come to hospice too late, when the time to really implement these wrap around services is too short, and the patient typically passes within days of admission. A lot of the front-end expense is getting a patient set up with care. So in this scenario, the hospice organization doesn’t make a lot of money.
But in the case of the recent headline, there’s another scenario to consider.
With more than 100 agencies competing for patients, the competition for patients can be fierce, and sometimes patients come to hospice care too soon. Some business development representatives for hospice organizations have recruitment quotas. And that can provide a subtle incentive to “stretch the rules” admitting patients who don’t really meet the “6 months or less” criteria to hospice care. The more patients a hospice provider has on any given day, the more daily payments it collects. These less sick, longer-term patients, who likely have fewer needs, balances out the patients who are only cared for for a few days. And it can stretch the organization’s finances to provide care and support to all patients when the focus is on how many patients they’re getting paid for.
This is a travesty to hospice organizations that are providing services according to the guidelines. There’s no question that hospice services are a critical cornerstone to holistic health care. But like most of our serpentine healthcare system, finding that care at the right time, with the right provider can have a dramatic impact on the end of life experience.
If you or a loved one has a life limiting diagnosis, understanding the overall role palliative care (more on that in an upcoming post) and hospice can play in your health care decisions can be vitally important. And it’s often helpful to contemplate and understand the parameters for when hospice care makes sense before it might be needed.
Whenever you might consider hospice for yourself or a loved one, though, keep that earlier lead sentence from the AJC article in mind: “….a burgeoning number of abusive hospice schemes.” Do your due diligence to not to be a part of one of them.
Visit these links to learn more about choosing a hospice program: