Growing national concerns about the rampant growth of hospice expenditures under Medicare, particularly for patients who have very long stays in hospice care and for the "cherry-picking" of more profitable patients by some hospices, received further momentum this week from an article in the New York Times (June 27, 2011). In a collaboration with Kaiser Health News, Jordan Rau reported that "the nation's bill for hospice care is rising at a staggering rate, prompting charges that many providers, particularly for-profit companies, are inappropriately enrolling patients."
Rau pointed out that Medicare outlays for hospice care more than quadrupled between 2000 and 2009, from $2.9 billion to $12 billion. The Medicare Payment Advisory Commission (MedPAC), the Office of Inspector General and the federal Centers for Medicare and Medicaid Services (CMS) are all concerned that this rampant growth is more a reflection of admitting long-stay patients who may not actually be terminally ill than of increased access to hospice care for the patients who truly need it. MedPAC, which advises Congress on Medicare policy, even proposed a plan to reform hospice payment under Medicare, which now pays hospices a flat per-diem rate for most of the days Medicare patients spend enrolled in hospice care, regardless of how many services or indeed if any services are provided on that particular day.
CMS has been ordered by Congress to test alternate payment approaches for hospice care, including MedPAC's proposed "U-shaped curve," which would pay hospices a higher rate for the first few days of care and for the last few days before the patient's death, which are known to be more expensive care to provide. But for the days in between for long-stay patients, the hospice would be paid at a lower rate.
Although the hospice industry has often complained about the kind of coverage seen in this week's Times article, it has been too slow to embrace accountability, self-policing and quantifiable demonstrations of quality for the care it provides to vulnerable, terminally ill patients and their families. Although some of the criticism of hospice care has oversimplified the industry's problems as a clash between for-profit and non-profit sectors, I think most consumers would be surprised to learn that for-profit companies now constitute half of the $12 billion U.S. hospice industry, which historically has been lauded for its compassion and idealism. In some cities, dozens of small, privately owned "mom-and-pop" hospices, some of them with marginal expertise and experience, now compete for limited hospice referrals but fail to demonstrate enhanced end-of-life care or access overall for those communities.
The Times article describes a whistleblower fraud case against "Trinity Hospice, a now-defunct Texas-based chain," which "strongly encouraged" its employees to find ways to keep patients on service as long as possible, whether they were dying or not. Any serious advocate for hospice care, which I consider myself to be, would feel a chill down their spine to hear that phrase, especially given the government's growing concerns about Medicare fraud. I believe it's time for America's hospices to step up to the plate and get serious about demonstrating their quality and accountability -- especially for long-stay patients and for patients with Alzheimer's disease, who are a particular focus of this week's Times article as well as for the government's Medicare watchdogs.