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A New Push for Hospice Reform

Apparently, there are people who wake up in the morning and ask how they might exploit terminally ill, elderly patients for their own personal financial gain.  It’s a business plan that works because the victim is usually dead, the family is exhausted and the morally bankrupt hospice owner is living the dream and needs Jesus.

For those of us who do not subscribe to this philosophy, known as psychopathy, we are fortunate that ProPublica along with the New Yorker investigated the state of hospice as we know it and published their results in November of 2022 in an article titled ‘How the Hospice Movement became a For Profit Hustle’. In an expose more telling than a National Enquirer story, these journalists wrote about how hospice fraud was occurring.  Worse, the information is true!

I’m proud to report that only one of my clients was mentioned in the article.  They likely over assessed a pregnant 32 year old woman with no other illnesses as being appropriate for hospice care.  I’m sure it was an honest mistake.  Her physician was very surprised. 

Of greater interest are the large, well known and usually respected hospice providers who have settled with Medicare. Maybe I’m overly optimistic but a 70 year old woman recertified for hospice 30 times seems a bit excessive.  After five years, the patient’s husband learned he could revoke hospice and did so.  His wife was weaned off of opiates and slowly returned to life.  Amedisys settled for 7.5M.  

This is better than Novus Hospice who took a different route to lowering their length of stay. They simply cut off the oxygen and overdosed patients.  About 15 people are in jail for Medicare Fraud but not mass murder.

We are reminded in this article that hospice became a real thing in the 1960’s.  It was imported from England where a dying patient’s “total pain” — his physical suffering, spiritual needs and existential disquiet.  The goal of hospice is to allow patients to die with dignity and to support the family.  Given the stated purpose of Hospice Care, it is not hard to imagine the outrage when Medicare or lawmakers attempt to curtail services to patients who are not appropriate.  

The Propublica article generated a lot of interest from the house of representatives and Hospice Industry Leaders and a few more.  It was like a competition to see who could write the best letter to the head of human services.  Results followed.

A list of 34 Recommendations has been tendered by multiple trade organizations working together.  The list may seem intimidating at first but many of the items are already being performed either by regulation or simply good practices.  There is also a 196 page document detailing potential changes to the State Operations Manual Hospice Survey guidance.   And yet, it occurs to me that if the rules and regulations in place were enforced, much of the fraud could be curtailed.

Looking at the patients that were highlighted in the Propublica and The New Yorker investigation and all the other examples of hospice fraud over the past few years, there seems to be one consistent failure.  Patients and often employees are not educated on the hospice  benefit.  Physicians are signing documents for no reason other than the hospice asked them to ‘sign here’.  Apparently, there’s an automated response when some physicians see a yellow arrow stuck on a paper to pull out a pen and apply their signature.

Home health and hospice nurses can help prevent inappropriate admissions to hospice.  When it becomes apparent that a patient is terminal, the home health or physician often recommends hospice care.  Home health nurses find it difficult to say, ‘It looks like we’re done here.  How about a little hospice care for your terminal illness?” That discussion may be left to the hospice.  A good hospice will ensure that the patient and or caregiver understands the Notice of Election before it is signed.  A sample notice of election can be found here.  Note that each field is required.  Additionally, Palmetto GBA has provided a hospice documentation audit tool which focuses on the Notice of Election. If a hospice chart can get through the documentation audit, it will likely be paid without question.

Apparently, not all hospices are as ethical as we would like.  Home Health nurses who are transferring patients to hospice care should make it very clear that further care from hospice will be for comfort measures only and that the patient will likely not live much longer.  Difficult conversations are part of nursing.  If you can ask for a raise, you can do the death conversation.

Perhaps the worst consequence of the increased fraud and resulting scrutiny in hospice care is that physicians may be reluctant to sign medical director contracts or patients will not be admitted to hospice when it is appropriate.  Home Health spent  years under the CMS microscope and it harmed agencies who provided good care only to have their claims denied because of a forgotten date or other clerical error.  When a business doesn’t have sufficient funds to produce the end product, quality suffers.  And hospice, for profit or non-profit is a business.

5 Comments Post a comment
  1. Gail #

    As a former Hospice and later Home Health RN, I am sorry to say, I am not shocked by your article. Lately, I have heard and read horror stories about “practices” brought into question by consumers and others curious about what all is entailed in Hospice care. My husband of 55 years passed away on Hospice in September. His care was superlative and appropriate. My former co-worker and friend at Home Health was the one who broached the subject of Hospice with me instead of re-admit him to Home Health. I am sure it wasn’t easy for her. But I knew in my heart and soul, it was time.
    Your first paragraph sums it up nicely. (Love the sarcasm.) I am afraid the “yellow arrow stuck on a piece of paper” is also quite accurate. Doctors are overwhelmed with excessive and obnoxious paperwork, and I sympathize, BUT not to the point of saying that this practice is OK.
    Unfortunately, consumers MUST educate themselves as to what is and is not appropriate. If we can’t police ourselves (healthcare) perhaps those who are recipients of healthcare can. The thought that nurses and others who are involved in this fraud and abuse can do these exploitive things is abhorrent and literally makes me nauseous. A “come to Jesus meeting” seems in order to me.

    February 28, 2023

    • Gail,

      I am so sorry to hear about your husband. Having felt that you and your husband were supported by hospice, you know how horrific those who commit fraud are. My fear is that hospice will be under so much scrutiny that it will be underused. A good hospice makes life, and death, so much easier.

      February 28, 2023
  2. Carol S. #

    I have worked in hospice and home health. I saw more abuses in home health in a rather unscrupulous for-profit agency than I ever saw in hospice. Usually the patient is referred so late in the game that they do not benefit fully from hospice. But sometimes that is ok. They were not ready. It sickens me that these things go on. I cannot imagine being a nurse and working for such a place. I was fortunate to have good experiences in caring upright agencies. Both my parents had hospice care also and they were wonderful. I love your frank style. These things need to be told, and no need to mince words. Nurses beware! I got caught in a bad agency once in home health and it was the biggest mistake of my life. Knowing that there are hospice agencies out there doing these things is so disturbing! Protect your licenses! If you find yourself caught in such a situation get out as soon as you can, and let the authorities know.

    February 28, 2023

    • To be honest, most of the hospice providers who have contracted my services are wonderful. Even when documentation is off or they forgot to renew a contract, the care delivered was stellar. Sometimes, I am asked to look at a hospice by a lawyer or uninvolved owner. It has been on some of those occasions that I stared at charts and couldn’t believe what I was seeing. Then, when I think I’ve seen everything, I read articles like this one or the Novus hospice story.

      But people who have had positive experiences with hospice but don’t work in the industry like you hear that the Feds are ‘cracking down’ on hospice providers and they think of how the needed hospice during those last days of someone’s life and the response is outrage. It is very difficult to educate the public without terrifying them. Maybe we need to identify and write about ways to find a good hospice.

      Another thought occurs to me. In order to bill Medicaid in some states, providers must attend an educational seminar. Why shouldn’t they be educated and tested on hospice rules, regulations and coverage guidelines before a license is issued or transferred? Nobody will be able claim they ‘didn’t know’.

      You’re point about being caught in a bad agency is relevant. How would a nurse know certain things if not taught. It seems that we are now responsible for educating ourselves because the feds rarely care if you were led astray or forged the path.

      February 28, 2023
  3. Carol S. #

    Yes! I knew what I knew because I had many years experience in good agencies. The nurses did not know better, management did. The staff was caught in the web and they were the ones who would have been blamed if an investigation had taken place. Your point is perfect. Education is so crucial!

    February 28, 2023

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