I just came back from the Association of Health Care Journalists conference in Atlanta, Ga., four days of networking with print, broadcast and web journalists who cover health care. I often said to those I met there that I have been writing about hospice care for many years, but increasingly my reporting has turned to covering regulatory scrutiny of hospice quality and eligibility, claims denials and Medicare payment recoupments, whistleblower and anti-Medicare fraud lawsuits against hospices, and government concerns about patterns of prolonged-stay patients. In virtually every case, I received a sad, knowing head nod in response.
Journalists are accustomed to looking for trouble, and they have other examples of health care fraud to draw upon. But it made me think that the depth of hospice’s “quality problem” –- which is also a compliance problem and a public relations problem –- is not fully appreciated by hospice industry leaders. The answer to this problem, I believe, is for hospices to get much more serious, systematic and public about how they address quality.
Hospice care, while not always well understood or sensibly utilized by patients or their physicians, used to be celebrated for its mission, its commitment to transforming end-of-life care in America, and its expert, compassionate care of dying patients. Something has turned, at least in my unscientific sampling of working journalists. It makes me wonder whether the recent spate of negative press for hospice by Bloomberg's Peter Waldman, Kaiser Health Network's Jordan Rau and others, the widely publicized lawsuits, MedPAC's critiques of hospice reimbursement and a veritable alphabet soup of government scrutinizers of hospice claims have reached critical mass -– risking a radioactive meltdown of the movement’s good name.
You could argue that much of the recent criticism of hospice has been unfair, that the government’s close scrutiny of hospice eligibility determinations ignores the impossibility of making accurate six-month-or-less prognoses, that the lack of nuance in its scrutiny fails to separate the good from the bad hospices, even that the government has failed in its responsibility to perform routine compliance surveys of hospices at reasonable intervals. And indeed that’s what hospices and their national organization say. However, that may all turn out to be beside the point -- insufficient in the court of public opinion.
Much of the recent bad press for hospices has emphasized the “for profits,” which seems over-simplified in a system where other health care provider types and professions are free to pursue profit in the marketplace. Certainly, problems in the quality of hospice care are not limited to the for-profits. But consider the nursing home industry, whose founders often were highly motivated to provide excellent long-term care for elders. Many nursing home operators today are non-profit and often highly committed to caring for challenging patients under a difficult system of heavy government regulation. But nursing homes generally must deal with a reputation that’s very different than what hospice care used to enjoy.
No doubt, the more sophisticated for-profit hospice chains have already budgeted for a similar kind of negative fallout and the costs of regulatory scrutiny and Medicare paybacks. If hospice’s reputation ends up looking more like the nursing home industry’s, hospice care would survive, and the services still would often be very good. But for those of us who remember what hospice’s mission and idealism once meant, something of incalculable value will have been lost.
At a workshop on hospital quality data reporting initiatives at the health care journalists’ conference, it was suggested that the best hospitals can be characterized by transparency: their candidness about quality problems and inevitable medical errors and what they’re doing to fix them; the quality measures they use and how they use them to improve; the role of quality outcomes in determining senior managers’ compensation -- even how often published minutes from board meetings reflect serious engagement with quality. I wonder if those same standards could -- and should -- become quality yardsticks for America’s hospices, as well.