Missed Visits, Uncontrolled Pain And Fraud: Report Says Hospices Lacks Oversight

Yves here. Hospices in theory offer an alternative to the US medical model that Lambert has described as “Insert tube, extract rent.” In practice, sadly, even patients in their closing months of life need to be vigilant about their choice of provider.

By Melissa Bailey, a Boston-based correspondent on the KHN enterprise team, focusing on aging and dying. Her stories have appeared in The Washington Post, TIME, USA Today, PBS, the Chicago Tribune and other publications. She was a 2015 Nieman Journalism Fellow and holds a math degree from Yale. Originally published at Kaiser Health News

Elderly patients spent over two weeks in uncontrolled pain or respiratory distress. Acute care was rare on weekends. And recruiters went door to door pitching fraudulent schemes, luring healthy patients to sign up for hospice in exchange for free housecleaning and medicine.

These details appear in a report on hospice released Monday by a government watchdog agency calling on federal regulators to ramp up oversight of a booming industry that served 1.4 million Americans in 2016.

The report from the Office of Inspector General (OIG) at the Department of Health and Human Services sums up over 10 years of research into inadequate care, inappropriate billing and outright fraud by hospices, which took in $16.7 billion in Medicare payments in 2016.

The Medicare hospice benefit aims to help patients live out their final days in peace and comfort: It pays for agencies to send nurses, aides, social workers and chaplains to visit patients who are likely to die within six months and who agree to forgo curative treatment for their terminal illness. Most of the time, this care takes place where the patient already lives — their home, nursing home or assisted living facility.

A Kaiser Health News investigation last year revealed that while many of the nation’s 4,000-plus hospices earn high satisfaction rates on family surveys, hundreds fell short of their obligations, abandoning families at the brink of death or skipping other services they had pledged to provide.

The OIG report points to similar gaps in care and raises concerns that some hospices are milking the system by skimping on services while taking in daily Medicare payments.

Regardless of how often their staff members visit, hospices collect the same daily flat rate from Medicare for each patient receiving routine care: $193 for the first 60 days, then $151 thereafter, with geographic adjustments as well as extra payments in a patient’s last week of life.

The report calls on the Centers for Medicare & Medicaid Services (CMS) to take 15 actions to improve oversight, including tying payment to quality of care and publishing public inspection reports on its consumer-focused website, Hospice Compare, as it does for nursing homes.

In a letter to OIG in response to an earlier draft of its report, CMS Administrator Seema Verma objected to those two recommendations as well as six others. She concurred with six other recommendations and wrote that CMS is “committed to ensuring that the Medicare hospice program provides quality care safe from fraud, waste, and abuse.”

The OIG findings include:

Basic care only: In 2016, 665 hospices provided only the most basic level of care, called routine home care. This is a red flag, OIG argues, suggesting that patients may not be getting the care they need: Medicare requires hospices to offer three other types of care — general inpatient care for acute conditions such as uncontrolled pain, continuous care in a crisis and respite care to offer a caregiver temporary relief.

Inadequate acute care: Hospices failed to provide adequate nursing, physician or medical social services in 9 percent of general inpatient care stays in 2012. Examples of poor care included a 101-year-old man with dementia who had uncontrolled pain for 16 days, and an 89-year-old man who had uncontrolled respiratory distress and anxiety for 14 days.

Weekend visits rare: Hospices rarely provided services on the weekends to patients in assisted living in 2012. Hospices were also more likely to provide general inpatient care on weekdays than on weekends, according to an OIG analysis of 2011 data.

Missing services: In nearly a third of Medicare claims filed for patients living in nursing homes, hospices provided fewer services than they promised in patients’ plans of care, according to a 2009 report. This is notable, the OIG argues, because hospices set their own plan of care for each patient, and fell short of the bars they established.

Few or no visits: On average, hospices provided only 4.8 hours of visits per week, in exchange for $1,100 in weekly Medicare payments, for each patient receiving routine home care in an assisted living facility in 2012, OIG found. Most visits came from aides. In addition, 210 of those patients did not receive any hospice visits that year, despite Medicare paying $2.3 million for their hospice care.

Responding to these findings in her letter, Verma said CMS has taken various actions, including: auditing certain hospices’ medical records before claims are paid, monitoring hospices that have many patients in nursing homes and recouping money from hospices that inappropriately billed Medicare for general inpatient care stays.

While many of OIG’s findings date back over five years, report lead author Nancy Harrison, deputy regional inspector general of the OIG’s New York office, said that the vulnerabilities in the system persist and that CMS has failed to implement many of the recommendations OIG has been making for years. These vulnerabilities have emerged at a time when the industry has changed rapidly, she said.

“Hospice is quite different than it used to be,” Harrison said. “When it started out, there were faith-based and nonprofits,” and most patients had cancer. As of 2016, there were 4,374 hospices receiving Medicare money, about two-thirds of which were for-profit.

Fraud has pervaded the industry, with some hospices ripping off taxpayers by enrolling patients who are not dying, paying kickbacks for patient referrals or carrying out various inappropriate billing schemes. From fiscal years 2013 to 2017, OIG investigators won back $143.9 million from 25 criminal actions and 66 civil actions against hospices.

Fraud has run wild in Mississippi, where hospices were paying recruiters to solicit business door to door from people who were not dying. The recruiters offered free housecleaning, medicine and doctors’ visits to patients who signed up — not knowing they were enrolling in hospice and forgoing Medicare payment for curative care, according to OIG field agents. One recruiter, a convicted sex offender, was sent to prison for 40 months in 2016 for taking payments from five hospices, earning $200 to $600 for each hospice-inappropriate Medicare beneficiary he sent their way.

Also in Mississippi, hospice owner Regina Swims-King was sentenced in 2014 to nearly six years in prison for an $8 million Medicare fraud scheme involving patients who did not need hospice, services that patients never received and claims based on forged doctors’ signatures. She forfeited 12 real estate properties and 17 vehicles, including a Rolls-Royce Phantom.

Charles Hackney, an assistant special agent in charge who oversees OIG investigators in Mississippi, said fraud there, which was perpetrated by small mom-and-pop operators, has subsided after many criminal convictions.

But nationally, fraud cases continue: Just last October, the federal government reached a $75 million settlement with Vitas Hospice Services — a large for-profit chain owned by Chemed Corp., which also owns the Roto-Rooter plumbing company — to address allegations of fraudulent billing.

Edo Banach, president of the National Hospice and Palliative Care Organization, an industry group, did not review the OIG report before publication. But in a statement, he said “incidents of deliberate fraud and abuse in the hospice community, though rare and isolated, are indefensible.”

He said his group aims to work with the Trump administration to “simplify and streamline the compliance process” in a way that “encourages honest and law-abiding hospice providers” while protecting against fraud.

Banach suggested the OIG also examine an issue not mentioned in the report: “underutilization of hospice care, which keeps too many Americans from accessing quality end-of-life care when they need it.”

KHN’s coverage of these topics is supported by John A. Hartford Foundation and Gordon and Betty Moore Foundation

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  1. sd

    We have an elderly parent with cancer who may one day face hospice. We have had fairly good experience with short term home care workers. There is one issue that stands out though. Pay is low so the aides pick up work with temp agencies to make more money which results in tired aides. And when people are tired, they make mistakes.

  2. Disturbed Voter

    Short term home care isn’t appropriate for severely disabled patients. That only works with “live at home” or “assisted living” situations … even if there is a relative nearby providing daily care also. At a certain point, with some elderly, they need full time nursing care, either at home, or in a nursing home. The first is usually financially out of reach, and the second has many problems, not least, resistance from the elderly.

  3. Louis Fyne

    this is disturbing, but not surprising.

    in our grapevine, staying at home during their last weeks when terminally ill (usually cancer) and then moving to hospice in final days (often in a coma or whacked out on opioid pain relievers) has become common.

    1. False Solace

      An aunt and uncle both chose this before they succumbed. It requires family members able and willing to do a lot of exhausting work without compensation, so I doubt it will be an option for most.

  4. JTMcPhee

    The vultures and looters are always circling.. venture capital is moving in for the kill. Hospice “care” is a fat carcass. Also in the picture are corporatization and eventual franchising for suicide spas and parlors, Forbes had an article on it not so long ago.

    I see “Death with Dignity” is a copyrighted phrase, belonging to a 501c3 of that name that has successfully lobbied the passage of assisted-suicide legislation in several states and DC itself. https://www.deathwithdignity.org/learn/advocates/

    And “Dying with Dignity” is copyrighted in Australia. The corps probably have been copyrighting all the other catchy names for death parlors, “Last Steps” and such.

    I will say, as a constant harper on the need for and effectiveness of organization, these people have created a very potent model for how to get legislation passed. With the help, no doubt, of the “explosively growing” “Just die” industry. Because Markets. Check out their site, their brags, their board membership to see how the have guided and massaged what they put forth as a concrete material benefit.

    One might ask why death help has such legs, and “life with dignity and universal health care” does not.

    The demand is obviously there and pent up, see “deaths from despair” everywhere. Why not use these as a last chance to bleed out the remaining savings of the mopes, and of course to legally “harvest,” as in carve out, a bunch of profitable body parts for sale to highest bidder? “Soylent Green” popularized the business model years ago…

    1. False Solace

      I agree that “death parlors” sounds pretty crass, but if the alternative is being milked for years in a soul-sucking nursing home and losing all the assets one hoped to pass on to family members, it is a rational choice.

      This country needs expanded and improved Medicare For All.

  5. Alex

    The quote at the end of the article really deserves more attention— one of the biggest problems with hospice care is that too *few* eligible people are able to use the hospice benefits to which they are entitled, because they are referred too late or not at all. The OIG often approaches health and human services compliance solely from the side of making sure no one is getting benefits they shouldn’t, but they hardly ever consider whether a program is fulfilling its mission to deliver benefits to those who should get them. As a result, more and more barriers to getting care are added in the name of compliance. You see the same thing over and over in things like adding an asset test for food stamps literally to deal with the extremely rare problem of lottery winners even knowing the bureaucratic burden will cost more than it saves and exclude tens of thousands of eligible folks who need food.

    1. JTMcPhee

      That exclusion is obviously the real unstated and effective goal of the those “programmatic improvements.”

  6. WendyS

    They tried to give my husband hospice care before they figured out what was wrong with him. They had him in the hospital here in Olympia for over a month then sent him home. He was only 62, I had to threaten them with a lawsuit before they finally took him up to the UW Medical center and figured out that he had cancer. Unfortunately it was a rare variation of lymphoma and they weren’t able to treat it.

  7. RUKidding

    Thanks for the information. Unsurprising that this “industry” is infested with scams and less than stellar work product.

    My parents were in hospice in their last 2 weeks of life, but they were fortunate enough to have excellent health care. The hospice workers were mostly all great. Note, though, that I said “mostly.”

    What my sibs and I found was that typically the weekend staff was less than stellar. Not bad, but definitely much less engaged and involved in their work. Therefore, less caring and concerned.

    Had my one sib and I not been there 24/7, we might have missed my dad going into distress. He clearly needed his morphine upped, but the nurse who came around was totally uncaring about his distress and pretty much blew us off. I had to demand that the supervisor (fortunately a shift change occurred and one of the “regulars” who knew my dad and cared about him came on) call the consulting dr to get his morphine dosage upped. I get it that nursing staff have to go through channels to do this, but clearly the weekend person couldn’t be bothered to take the extra step.

    Lesson learned: I have no kids but am extremely good to my neices and nephews (I would be anyway). I know I’ll want to have someone advocating for me at the end. You just never know what will happen.

    And yet another crapification occurs. Caveat emptor.

    1. Louis Fyne

      this is one aspect from neoliberals about frictionless, liquid labor markets! that makes me boil—-they literally see zero economic value in having your immediate or extended family close-by. in their worldview it’s only logical that families disperse to the 4 corners of the country to maximize pay.

      I take regularly accompany my aunt to her cancer treatments and doctor visits. Often we have a train of extended family tag along for moral support.

      In the waiting room, the majority of patients are by themselves. Patiently, quietly biding their time to be called by the reception desk. Their faces look alone, resigned and sad. I hope that I’m just projecting and that’s not the case when they get home.

      Absolutely everyone needs an advocate/fiduciary who’s looking out for you if you’re ever in a serious health situation. And you can’t buy that on the free market.

      1. MyLessThanPrimeBeef

        Yes, unfortunately, that today, people move around a lot and families are scattered all over.

        Will the children be able to come back all the way from their menial jobs in far away places?

        As for corporations moving in, are we saying that, when it started out, it was more trustworthy with faith-based operators? Is religion not so bad, at least in this instance?

        1. JTMcPhee

          Not just “faith-based.” There were a lot of truly caring non-religious secular humanist nurses who saw a calling in tending to dying people. From what I hear, large numbers of them have been driven off by making dying into just another business lootitarium…

  8. sharonsj

    It’s always “follow the money.” The politicians don’t do anything about enforcing regulations because of bribes and/or campaign contributions.

    When my sister went into hospice in the last days of her life, we were “lucky” that the hospice was located inside a hospital, so that doctors and nurses were always available.

  9. Kris Alman

    I was appalled to learn that for-profit hospice care exists a decade ago when our father was placed in an assisted living facility. We thought this Medicare benefit could help ease his suffering. But the caregivers made things a mess when they took over his medicines–even though they were already covered by the VA. They didn’t fill his heart medicines and refused to come in on the weekend to do so. By the following Monday, he was in congestive heart failure, which was relieved with morphine. Unsurprisingly, my dad liked that feeling and wasn’t too perturbed. I told my mom to fire them on the spot.

    Soon afterwards, my father was hospitalized after a fall. On discharge, he was admitted to a skilled nursing facility. Hospice caregivers lurk in the hallways like lawyers after a plane crash when that happens. That’s because hospice vies with skilled nursing facilities as an either/or benefit of Medicare. Faced with that choice, it makes no sense to give up SNF benefits for hospice since the SNF has all the ability to give comfort care. But how many families would understand that?

  10. Bobby Gladd

    I count myself lucky. Lost my younger daughter to pancreatic cancer several months ago. She was a Kaiser-Permanente member. When it came time for home hospice, we were handed off to Kindred Hospice, one of their contractors. They could not have been better. On-call 24/7, never missed a scheduled home visit, delivered everything we needed without fail. One of my biggest anxieties was she’d die in uncontrollable pain. They made sure that that would not happen. We subsequently turned in a boatload of leftover drug-dealers’-dream opioid pain meds to the local police department.

    It was 100% covered. And, broadly, Kaiser lost their butts on her 14 months of care post-dx (she’d been a recent “Covered California” signup, a mere 4 month prior to her diagnosis). They never scrimped on her care or put any sand in her gears.

    A rare good story.

    I will have to cite this article. Already tweeted it.

  11. precariat

    With regard to parents: I can attest to the lack of information, preparation and sparse vists with at home hospice through Medicaid c. 2001. Later with the other parent who had federal retired employee insurance the vists were regular, attention to pain and care were infinitely better.

    Even when a patient decides to spare the medical system a hospital stay and continued treatment, their economic status dictates how they will be cared for – or not – in America. The toll on the caretakers dealing with substandard care –especially if there is little family or social support can be traumatizing.

    1. judy sixbey

      I have nothing but good things to say about the hospice care my mother received. She lived three months after a diagnosis of lung cancer at age 97. Even with constant care provided by my sister, who moved in with my mother, and me, it was tough going. Hospice nurses made it bearable. She was able to die at home as she wished. I would hate to see this service scammed and disrupted. By the way, reading Naked Capitalism in the wee hours of the morning helped as well.

    2. Left in Wisconsin

      My dad only had hospice for a week before he died but they were very good. But I have to say, this piece told me a lot about how hospice works that I didn’t know – including the daily fees they collect. And I did everything I could to be extremely informed about Medicare and everything related to his health care in the last 18 months he spent with me. For most people, I would have to think hospice is a complete mystery and they are in no position to ascertain whether they are getting appropriate care or the care they deserve.

  12. Schmoe

    A hospice service recently tried to “recruit” my 92 year old father who is an assisted living memory care unit. Their comments on his condition were far more dire than my sister’s or my perception of his condition and he is fairly stable, other than deteriorating eyesight. It felt like they were really looking for new patients and we declined their officer of services for the time being.

    1. DHG

      Interesting you should post this. I received a call from my mothers doctors office nurse practitioner last week who stated that her condition had depreciated quickly over the last week and that they wanted to move her to hospice care.. I was stunned as I had just seen her Wed and another friend of hers had just seen her Friday the day I got the call. I refused and just ordered continuation of the care she was already getting at the nursing home. I went up Sunday and there was no decline at all from the visit I had Wed or any appreciable difference at all. Angers me, I am considering a complaint to the State on all this.

  13. southern appalachian

    My experiences over the last few years have for the most part been excellent – only one of the organizations was a for-profit. They were not as present as the others, but we were in a very rural location, way up in the mountains and hard to reach. For-profit Hospice organizations scare me, but – well, lots of stories. Reflective of the precariat and disintegration of communities and families. Hard work, and you need help. Sometimes there is none, no one there. Seems increasingly difficult to find a primary caregiver, people work erratic schedules, sometimes the pain medicine walks out the door. But there are other stories, the majority, grounded and solid through a hard and ethereal time.

    For-profit looks as if it’s the future though – less and less room in our culture for the unavoidable treks across the liminal.

    Anyway. I’ve heard of instances of spectacularly bad care so glad someone took the trouble to look into it a bit.

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