Hospice treatment focuses on providing comfort to the terminally ill, not finding a cure. To enrol a patient, two doctors certify a life expectancy of six months or less.
But over the past decade, the number of “hospice survivors” in the US has risen dramatically, in part because hospice companies earn more by enrolling patients who aren’t actually dying, an investigation by The Washington Post has found.
Healthier patients are more profitable because they require fewer visits from medical professionals and stay enrolled with a hospice longer. The proportion of patients who were discharged alive from hospice care rose by about 50 per cent between 2002 and 2012, according to analysis of more than 1m hospice patients’ records over 11 years in California, a state that makes public detailed descriptions and that, by virtue of its size, offers a portrait of the industry.
The average length of a stay in hospice care also jumped substantially over that time, in California and nationally. Profit per patient quintupled, to $1,975 (£1,195), California records show. This vast growth took place as the hospice movement, once led by religious and community organisations, was evolving into a $17bn industry dominated by for-profit companies. Much of that is paid for by the US government – roughly $15bn of industry revenue last year came from Medicare, the federal government’s social insurance programme.
At AseraCare, for example, one of the nation’s largest for-profit chains, about 78 per cent of patients who enrolled at the branch in Mobile, Alabama left the hospice’s care alive, company figures show. Up to 59 per cent of patients left the AseraCare branch in nearby Foley alive. And at the one in Monroeville, 48 per cent were discharged from the hospice alive. “It was definitely good news,” said Bessie Blount, whose father received hospice care at the Monroeville centre and left after about a year. Three years later, her father, Chocolate Blount, 91, is still alive.
The work that the hospice nurses, aides and counsellors do, often in the most trying circumstances, is demanding, emotionally and physically. It typically allows patients to die at home or in other familiar surroundings – and for families of the dying, the comfort it offers can provide enormous relief. But the survival rates at AseraCare are emblematic of a problem facing Medicare, which has created a financial incentive for hospice companies to find patients well before death.
Medicare pays a hospice about $150 a day per patient for routine care, regardless of whether the company sends a nurse or any other worker out on that day. That means healthier patients, who generally need less help and live longer, yield more profits.
In 2011, nearly 60 per cent of Medicare’s hospice expenditure of $13.8bn went toward patients who stay on hospice care longer than six months, MedPAC, the Medicare watchdog group created by Congress, has reported. Some of those patients simply outlived a legitimate prognosis of six months. But much of the data suggests the trend toward longer stays is a response to the financial incentive.
Consider the difference between the non-profit and for-profit hospices. While the average non-profit serves a patient for 69 days, the average for-profit hospice serves a patient for an average of 102 days, according to MedPAC.Moreover, multiple allegations have arisen from former hospice workers who say that the businesses took in people who were not in declining health. Four of the 10 largest hospice companies in the US, including AseraCare, have been sued by whistleblowers alleging that patients were receiving care they did not need. The Justice Department has joined several of these lawsuits, including the one against AseraCare and Vitas, the nation’s largest hospice provider. Both companies deny wrongdoing.
Jim Barger, a lawyer in Birmingham, Alabama who has filed several of the suits, said the root of the problem is that a company profits when it admits patients who are not dying, and it is the hospice itself that helps determine whether a patient is dying. While two doctors certify a patient for hospice care initially, the patient must periodically be re-approved for hospice care. The re-approvals typically are done by hospice physicians.
“Honestly, it makes me ill,” Mr Barger said. Because of the lawsuits, “[legal] defence firms make money and my firm has made money. I’d like nothing better at this point than for my job to become obsolete. It must be strange to be told you’re dying and then not die.”
For five years, Medicare’s watchdog group has been recommending that the payments to hospice companies be revised to eliminate the financial incentive for improper care, but Medicare has not yet done so. To ensure that patients are appropriately selected for hospice care, Medicare relies on strict medical documentation requirements, a spokesman said.
Jonathan Keyserling, the senior vice-president of health policy at the National Hospice and Palliative Care Organisation, an industry group, said the current payment system was sound and that tampering with it could have unintended consequences.
Mr Keyserling and others in the industry attribute the rise in the number of hospice survivors to changing demographics: a larger portion of patients today have diseases, such as Alzheimer’s, whose outcomes are harder to predict.
© The Washington Post