Hospice Care Lifts Profits, Raises Questions

[Zeno Swijtink]

Hospice Care Lifts Profits, Raises Questions
BRETT COUGHLIN - Politico

Data released Thursday suggest that the long-term care industry is an economic juggernaut, but an ongoing inspector general investigation is examining how nursing homes have incorporated hospice care into their business model and whether that’s good for patients or Medicare.

The data, released today the American Health Care Association, show that in 20 states, long-term care is one of the top 10 employers. In eight states - California, Florida, Illinois, Texas, Pennsylvania, North Carolina, Ohio and New York - the industry provides more than 100,000 jobs.

'In this economic engine that is the American economy, long-term care is one of the pistons, consistently firing even in the worst of hardships,’ Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living and a former Republican governor from Kansas, told POLITICO. 'Because of $45 billion in Medicaid every year by federal and state governments, we are able to generate $529 billion in total economic activity, support and create over 5.4 million jobs, and return over $60 billion in taxes back to federal and state coffers annually,’ he said.

One of the little-known drivers of this revenue is a growing trend of hospice within the nursing home. Federal spending on hospice has tripled between 2000 and 2007 - and much of that money is being misspent, suggests a Kansas physician who has been pushing hard to reverse the trend.

According to Medicare data, almost 40 percent of Medicare patients who died in 2005 had elected hospice. By 2007, almost 1 million patients were in hospice, and Medicare spending for the benefit had more than tripled from $2.9 billion in 2000 to just over $10 billion.

The Medicare Payment Advisory Commission weighed in, and weighed in hard, last year, recommending to Congress that the Department of Health and Human Services’ inspector general investigate the 'prevalence of financial relationships between hospices and long-term care facilities’ including nursing homes to determine whether there may be a 'conflict of interest.’ The conflict could come in as nursing home staff influence admissions to hospice.

The commission also wants the IG to look at differences in patterns of nursing home referrals and the enrollment process and to look for spikes in enrollment. MedPAC also asked the IG to examine the 'appropriateness of hospice marketing materials’ and admissions practices to determine if there are any 'potential correlations between length of stay and deficiencies in marketing or admissions practices.’

Greg Christ, vice president of public affairs for AHCA, said that 'our members treat every hospice resident in a holistic way, completely attuned to their needs.’ He said this means that each patient is treated in a 'very singular, individualistic fashion.’ About controlling costs, he said that nursing homes are 'coordinating with hospitals and other providers more than ever before; something that will ensure patients are in the most appropriate, least restrictive setting for them.’

Providers suggest that this is a difficult balance to strike.

'Medicare is in trouble, and we need to take care of people, but spend money wisely,’ said Larry Anderson, a family physician at the Sumner County Family Care Center in Wellington, Kan.

Anderson has pushed for reform of hospice, saying it needs to go back to the original intent of the policy: patient-centered care given in the home, not the nursing home.

'The only way it’s going to work, that I can see, is get hospice out of nursing homes. Because, right now the patients, the families are so into this, there’s no way to stop it,’ he told POLITICO.

Contrary to popular belief, many patients receive less care when certified as hospice patients in the nursing home, rather than more, Anderson said.

A Centers for Medicare and Medicaid Services official largely confirmed this.

'We have received input from past OIG’s investigations that have found that hospice patients who reside in a nursing home receive fewer nursing and aide services from hospice staff than hospice patients who reside in their own home. The OIG has also raised concerns about whether or not these patients were properly certified as being terminally ill and if they had in fact elected to receive Medicare hospice,’ a CMS spokesman told POLITICO.

Anderson tried to get the Kansas Medical Society and the American Academy of Family Physicians to pass resolutions to bring attention these problems and get hospice out of nursing homes.

The HHS inspector general has also been looking to quantify the issue. In 1997 it released a report on hospice and nursing home 'contractual relationships’ that raised questions about how the two industries were merging.

It took CMS until 2009, however, to begin random audits of hospice in nursing homes.

Anderson wants to cut to the chase: Only a sliver of nursing-home-based hospice is not-for-profit, which should be a big red flag, he said.

'OIG does absolutely nothing. Back in 1997 they knew about this and nothing has happened. Maybe it’s the politicians?’ he said. 'Driving the trend is - what else? - money.’

He said that one of the big problems is the payments for hospice in nursing home. The flat rate for nursing home care is between $110 to $130 a day, on average. But when a patient is added to hospice, Medicare pays an additional $130 dollars a day.

But moving all hospice patients out of nursing homes and into their own homes may not work, said Terry Berthelot, an attorney and former social worker now with the Center for Medicare Advocacy.

Berthelot noted that a significant portion of nursing home/hospice patients have no home to go home to.

'I think that would be a mistake,’ Berthelot said about making hospice only a home-based program.

At the heart of the problem, Anderson said, is the constant push by family members to get better care for Mom or Dad. If one doctor won’t certify that a patient is eligible for hospice - meaning the clinical evidence supports the prognosis that the patient is terminally ill and has six months or less to live - then another will, Anderson said.

Looking over the data from CMS, Anderson points to random audits by the agency that have found that as many as 49 percent of some hospice agency patients reside in nursing homes, and of that number, 29 percent were 'found to be ineligible for Medicare-funded hospice services,’ according to a pair of 1997 inspector general reports.

Anderson related a recent conversation with a hospice director who said that as many as 85 percent of their hospice agency patients in the Wichita area reside in nursing homes.

The new health reform law also calls on HHS/CMS to revise payment for hospice, saying the 'Secretary shall’ implement the changes.

CMS officials said that the health reform law (Sec. 3132) authorizes collection of additional hospice data to 'revise payments for hospice care,’ and this is being worked up for an Oct. 1, 2013 deadline.

An industry source defended the placement of hospice in nursing homes, saying: 'It’s a good choice for care at the end of life that is offered for patients, geared especially toward palliative care, the pain. It’s a very specialized service, and we are very comfortable offering this service in a nursing home.’

One change called for in the new health law requires a face-to-face assessment at the beginning of care to certify that the patient is eligible for hospice. Then, after six months, a face-to-face recertification has to be done.

'I think that type of new requirement could go a long way to helping that the patients are meeting the criteria for hospice care and are clearly qualified for this care,’ the industry source said.

[Barrie]

As a Hospice volunteer and as the daughter of a man who died in a nursing home with Hospice care, I think that Hospice is very useful to people dying in nursing homes. Hospice care givers are oriented to the care of the dying, other medical providers tend to fell like they are failing if the patient is dying. When Hospice stepped in for my father he got the care that he desperately needed because the nurse practioner really knew what was needed at life's end. He was suffering a great deal before she arrived. I'm sure that the finances can be worked out and the services retained. I have visited patients dying in nursing homes who have no relatives in the area, we became friends, I was one of the few visitors these people had and became an important part of their emotional support. People, especially in our culture, are so uncomfortable with death and dying that it is VERY important for dying people to have the support of medical, social, and spiritual rescources of Hospice. Barrie

Hospice Care Lifts Profits, Raises Questions
BRETT COUGHLIN - Politico

Data released Thursday suggest that the long-term care industry is an economic juggernaut, but an ongoing inspector general investigation is examining how nursing homes have incorporated hospice care into their business model and whether that’s good for patients or Medicare.

The data, released today the American Health Care Association, show that in 20 states, long-term care is one of the top 10 employers. In eight states - California, Florida, Illinois, Texas, Pennsylvania, North Carolina, Ohio and New York - the industry provides more than 100,000 jobs.

'In this economic engine that is the American economy, long-term care is one of the pistons, consistently firing even in the worst of hardships,’ Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living and a former Republican governor from Kansas, told POLITICO. 'Because of $45 billion in Medicaid every year by federal and state governments, we are able to generate $529 billion in total economic activity, support and create over 5.4 million jobs, and return over $60 billion in taxes back to federal and state coffers annually,’ he said.

One of the little-known drivers of this revenue is a growing trend of hospice within the nursing home. Federal spending on hospice has tripled between 2000 and 2007 - and much of that money is being misspent, suggests a Kansas physician who has been pushing hard to reverse the trend.

According to Medicare data, almost 40 percent of Medicare patients who died in 2005 had elected hospice. By 2007, almost 1 million patients were in hospice, and Medicare spending for the benefit had more than tripled from $2.9 billion in 2000 to just over $10 billion.

The Medicare Payment Advisory Commission weighed in, and weighed in hard, last year, recommending to Congress that the Department of Health and Human Services’ inspector general investigate the 'prevalence of financial relationships between hospices and long-term care facilities’ including nursing homes to determine whether there may be a 'conflict of interest.’ The conflict could come in as nursing home staff influence admissions to hospice.

The commission also wants the IG to look at differences in patterns of nursing home referrals and the enrollment process and to look for spikes in enrollment. MedPAC also asked the IG to examine the 'appropriateness of hospice marketing materials’ and admissions practices to determine if there are any 'potential correlations between length of stay and deficiencies in marketing or admissions practices.’

Greg Christ, vice president of public affairs for AHCA, said that 'our members treat every hospice resident in a holistic way, completely attuned to their needs.’ He said this means that each patient is treated in a 'very singular, individualistic fashion.’ About controlling costs, he said that nursing homes are 'coordinating with hospitals and other providers more than ever before; something that will ensure patients are in the most appropriate, least restrictive setting for them.’

Providers suggest that this is a difficult balance to strike.

'Medicare is in trouble, and we need to take care of people, but spend money wisely,’ said Larry Anderson, a family physician at the Sumner County Family Care Center in Wellington, Kan.

Anderson has pushed for reform of hospice, saying it needs to go back to the original intent of the policy: patient-centered care given in the home, not the nursing home.

'The only way it’s going to work, that I can see, is get hospice out of nursing homes. Because, right now the patients, the families are so into this, there’s no way to stop it,’ he told POLITICO.

Contrary to popular belief, many patients receive less care when certified as hospice patients in the nursing home, rather than more, Anderson said.

A Centers for Medicare and Medicaid Services official largely confirmed this.

'We have received input from past OIG’s investigations that have found that hospice patients who reside in a nursing home receive fewer nursing and aide services from hospice staff than hospice patients who reside in their own home. The OIG has also raised concerns about whether or not these patients were properly certified as being terminally ill and if they had in fact elected to receive Medicare hospice,’ a CMS spokesman told POLITICO.

Anderson tried to get the Kansas Medical Society and the American Academy of Family Physicians to pass resolutions to bring attention these problems and get hospice out of nursing homes.

The HHS inspector general has also been looking to quantify the issue. In 1997 it released a report on hospice and nursing home 'contractual relationships’ that raised questions about how the two industries were merging.

It took CMS until 2009, however, to begin random audits of hospice in nursing homes.

Anderson wants to cut to the chase: Only a sliver of nursing-home-based hospice is not-for-profit, which should be a big red flag, he said.

'OIG does absolutely nothing. Back in 1997 they knew about this and nothing has happened. Maybe it’s the politicians?’ he said. 'Driving the trend is - what else? - money.’

He said that one of the big problems is the payments for hospice in nursing home. The flat rate for nursing home care is between $110 to $130 a day, on average. But when a patient is added to hospice, Medicare pays an additional $130 dollars a day.

But moving all hospice patients out of nursing homes and into their own homes may not work, said Terry Berthelot, an attorney and former social worker now with the Center for Medicare Advocacy.

Berthelot noted that a significant portion of nursing home/hospice patients have no home to go home to.

'I think that would be a mistake,’ Berthelot said about making hospice only a home-based program.

At the heart of the problem, Anderson said, is the constant push by family members to get better care for Mom or Dad. If one doctor won’t certify that a patient is eligible for hospice - meaning the clinical evidence supports the prognosis that the patient is terminally ill and has six months or less to live - then another will, Anderson said.

Looking over the data from CMS, Anderson points to random audits by the agency that have found that as many as 49 percent of some hospice agency patients reside in nursing homes, and of that number, 29 percent were 'found to be ineligible for Medicare-funded hospice services,’ according to a pair of 1997 inspector general reports.

Anderson related a recent conversation with a hospice director who said that as many as 85 percent of their hospice agency patients in the Wichita area reside in nursing homes.

The new health reform law also calls on HHS/CMS to revise payment for hospice, saying the 'Secretary shall’ implement the changes.

CMS officials said that the health reform law (Sec. 3132) authorizes collection of additional hospice data to 'revise payments for hospice care,’ and this is being worked up for an Oct. 1, 2013 deadline.

An industry source defended the placement of hospice in nursing homes, saying: 'It’s a good choice for care at the end of life that is offered for patients, geared especially toward palliative care, the pain. It’s a very specialized service, and we are very comfortable offering this service in a nursing home.’

One change called for in the new health law requires a face-to-face assessment at the beginning of care to certify that the patient is eligible for hospice. Then, after six months, a face-to-face recertification has to be done.

'I think that type of new requirement could go a long way to helping that the patients are meeting the criteria for hospice care and are clearly qualified for this care,’ the industry source said.