JustCare

Tag: Hospice

  • John Oliver: The Medicare hospice scam

    John Oliver: The Medicare hospice scam

    Hospice offers comfort care for people with six months or less to live. Medicare covers hospice care. But, unscrupulous hospice agencies manipulate the Medicare hospice benefit for their benefit, John Oliver reports on Last Week Tonight.

    About 1.8 million people with Medicare receive hospice care each year. Hospices can provide critical support for patients and their families. The best hospices spend a few hours a day several days a week with patients; they rarely offer round-the-clock care so people usually need caregivers at home to care for them when the hospice staff are not there. Unfortunately, many hospice agencies have been found to engage in fraud, costing Medicare hundreds of millions of dollars every year.

    An English doctor and social worker came up with the notion of hospice to allow patients at the end of life to spend their last few months in peace with social and emotional supports. People in the US began receiving hospice services in 1974.

    Six thousand hospice providers in the US today are for-profit. Medicare generally pays them about $200 a day for each hospice patient, regardless of the actual amount of care they deliver. They can earn $1,500 a day for “crisis care.” Bad actor hospices try to sign up as many patients as possible and deliver as little care to them as possible.

    Hospices collect Medicare payment and then maximize their profits by providing little or no services. Oliver reports some instances of “severe neglect.” In many cases, the hospices simply phone patients to check in on them.

    Agencies bill Medicare for patients in hospice who do not belong in hospice. Sometimes hospices enroll patients who are not terminally ill to increase their revenue and defraud Medicare. In California, some hospices have discharged more than 50 percent of their patients without their dying.

    Physicians are required to certify that people qualify for Medicare hospice. But, hospices pay physicians to declare patients are terminally ill when they are not. One physician received a kickback of $250 a patient for certifying patients who were not terminally ill as terminally ill.

    Here’s more from Just Care:

  • Medicare Advantage: Hospice care is a juggle

    Medicare Advantage: Hospice care is a juggle

    Insurers clearly have not figured out how to profit from the Medicare hospice benefit, which offers comfort care for people who are terminally ill. Caitlin Owens reports for Axios that a government trial to include the Medicare hospice benefit in Medicare Advantage is ending six years sooner than planned because insurers and hospice agencies alike cannot make the benefit work to their liking. The Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, claims the pilot was not a failure. What would you call it?

    Right now, if you are enrolled in a Medicare Advantage plan and elect the Medicare hospice benefit–choose to forgo curative treatments for your condition in favor of palliative care–traditional Medicare covers the hospice services, even though you are still enrolled in a Medicare Advantage plan. [N.B. Unfortunately, the hospice benefit is only truly available to people who have someone to take care of them at home and ensure their safety when the hospice aides are not there. The hospice benefit does not provide 24 hour care.]

    Juggling between traditional Medicare for your hospice care and Medicare Advantage for all unrelated health care services can be a bear. And, it can be a big bear for the more than 800,000 people enrolled in Medicare Advantage who elected hospice in 2022–about half the Medicare Advantage enrollees who died in 2022.

    In 2021, the Center for Medicare and Medicaid Innovation (CMMI) launched a pilot to permit insurers offering Medicare Advantage to coordinate hospice care for their enrollees directly. The question is whether Medicare Advantage plans can make getting hospice services easier for their enrollees, bring down costs, and improve quality of care. The pilot was scheduled to run through 2030.

    The Medicare Advantage hospice experiment will now end in 2026. Neither UnitedHealth Group nor Elevance, two of the biggest insurance companies offering Medicare Advantage, who had been part of the pilot, wanted to continue participating. Only 13 insurers were participating.

    For the most part, hospices agencies were pleased that the insurers pulled out. Insurers were not paying them adequately and their administrative burdens were significant. But, without a hospice benefit, Medicare Advantage cannot provide seamless care at the end of life; it makes Medicare Advantage accountability and enrollee costs all the more complicated for hospice enrollees.

    Here’s more from Just Care:

  • Choose your hospice provider carefully

    Choose your hospice provider carefully

    Hospice care has grown in popularity for people with terminal conditions who seek comfort care rather than curative treatment. But, now, more than ever, you need to choose your hospice provider carefully. Ava Kofman continues to write for Pro Publica on how profiteers have taken over hospice in the US, at huge financial cost to the Medicare program and huge risk to patients at the end of life.

    As a result in significant part of Kofman’s earlier reporting, described in this Just Care post, the Centers for Medicare and Medicaid Services (CMS) conducted more hospice inspections. But, CMS continues to certify new hospices, even in California, where the state has banned new hospice licenses because of mounting hospice fraud.

    It appears that CMS does not have the ability or desire to close down hospices engaging in fraud. After visits to 7,000 hospices, CMS stopped just 46 of them from billing the government for their services. The travesty: The 46 hospices were nonoperational.

    CMS claims that it’s up to the states to stop the proliferation of hospices. CMS appears to be unwilling or unable to prevent even fraudulent or unneeded hospices from receiving certifications to deliver the hospice benefit to people with Medicare.

    Arizona, California, Nevada and Texas have seen a huge spike in the number of its hospice providers. CMS showed marginal concern at best about fraudulent bills from these hospices and the lack of need for additional hospices in these states. CMS said it would look at their bills more closely.

    California attempted to put a moratorium on new hospices in its state, with little success. Its auditors detected “a large-scale, targeted effort to defraud Medicare.” Hospice providers charged Medicare for patients who were not terminally ill and sometimes for patients who were fictitious.

    Notwithstanding California’s good oversight, CMS is allowing these hospice providers to bill Medicare for their “services.” CMS claims to need “evidence of sanctions” against a hospice in order to block a hospice from the Medicare program.

    In California, people enrolled in hospice fraudulently—people who are not terminally ill or who do not want hospice—are reportedly at risk of not getting needed care. Medicare covers hospice services only for patients who agree not to receive curative care for their conditions. That said, they should be able to get care for any condition unrelated to a terminal condition. Moreover, they are also always able to opt out of hospice to get curative care.

    In one case, a nursing home resident with dementia was fraudulently enrolled in hospice by a doctor she did not know. Medicare paid the hospice $7,500. But, the patient lost her ability to have her pacemaker checked and to receive physical therapy. CMS is now investigating.

    Here’s more from Just Care:

  • Profiteers turn hospice into a $22 billion industry

    Profiteers turn hospice into a $22 billion industry

    Ava Kofman writes for the New Yorker on the profiteers who have turned hospice care into a $22 billion dollar a year industry. Rather than being about dying with dignity, hospice is too often all about the money. Since quality varies tremendously, it’s critical to choose a hospice agency carefully.

    Today, about half of all Americans choose hospice at the end of life. With hospice, people deemed to have six months or less to live choose to forgo treatment for their medical conditions and instead receive palliative care to ensure their comfort. But, now that corporations see the dollar signs in hospice, electing hospice care can pose risks for patients. (N.B. People with Medicare can opt out of hospice at any time and receive Medicare-covered treatment for their conditions.)

    People tend to learn about hospice from their treating physicians. But, some for-profit hospices hire staff to scout out hospice patients. Hospice staff offer vulnerable people free medicine, nursing care and more if they’ll sign up for hospice, regardless of whether they actually qualify for hospice.

    Hospice agencies sometimes set “ungodly quotas” on their sales teams, expecting them to find large numbers of people who qualify for the hospice benefit. To meet their quotas, hospice staff recruit people into hospice who are not terminally ill but who the hospice agency can certify as terminally ill.

    At AseraCare, Kofman reports that staff are trained to turn chronic conditions like shortness of breath into a terminal condition, so that patients qualify for hospice. The corporations know exactly how to tap into government dollars. Often, they are running nursing home chains as well. Private equity also is in the hospice business.

    Much like Medicare Advantage plans, which often have histories of committing fraud or of settling fraud claims with the government, some hospice companies have similar histories. But, the government continues contracting with them. Consequently, Kofman reports that “companies in the hospice business can expect some of the biggest returns for the least amount of effort of any sector in American health care.”

    Medicare pays a flat daily rate to the hospice, even if it delivers few services. Medicare only requires the hospice to send a nurse to visit hospice patients twice a month. Medicare does require repayment from hospice agencies if their hospice patient population overall lives longer than six months. But, the agencies can get around that–they simply drop patients before the six months elapse.

    Hospice should ensure a person’s end of life is as good and comfortable as possible. It also should reduce health care costs because comfort care is far less expensive than hospitalizations at the end of life. But, in the hands of profiteers, who take the money paid them and don’t offer compassionate care, it is a huge waste.

    The Centers for Medicare and Medicaid Services (CMS) appears to do a poor job of overseeing the hospices it contracts with. One review of hospices found that most hospices had serious failings. Hospice agencies did not manage pain as required or have trained staff. But, as with Medicare Advantage plans, CMS almost never punishes the bad actors.

    What will Congress do about this?

    Here’s more from Just Care:

  • Private equity-owned hospice and home health agencies drive up Medicare spending, jeopardize quality of care

    Private equity-owned hospice and home health agencies drive up Medicare spending, jeopardize quality of care

    Jake Johnson writes for Common Dreams about a new report from the Private Equity Stakeholder Project that focuses on private equity’s “disastrous” hold on home health care and hospice care. Vulnerable older adults and people with disabilities are paying a high price, as is the Medicare program. Congress is sitting back and watching.

    Non-profit agencies once provided most home health and hospice services. Today, for-profit companies have taken over the majority of these two industries. Two in three hospices are for-profit and two in five home health care agencies are for-profit. Private equity has invested heavily in the corporations that own these agencies.

    Medicare home health care and hospice care can be good money for corporations, so long as care is limited and low-cost. So, they are likely working to get more people to take advantage of these benefits. More Medicare investment in this care would be wonderful–many people who would benefit from this coverage are unaware they are eligible for it–if the money is being spent wisely and being directed towards more people with Medicare who want and need these benefits.

    But, if private equity investment in nursing homes and PACE programs is any indication, people are getting far lower quality hospice and home health care from companies with private equity backing, and Medicare is spending more than it should for their care. Private equity ownership of nursing homes is associated with poorer care and more deaths. The home health and hospice industries are even less regulated than nursing homes.

    With private equity, profits come first. The cost to vulnerable older adults and people with disabilities receiving care from private-equity backed companies is likely high but hard to measure. In a 2021 Congressional hearing on private-equity owned nursing homes, Congressman Bill Pascrell of New Jersey asked, “How many grandmothers and grandfathers died because profits were prized above lives, with our taxpayer dollars funding this?”

    So, are any private-equity owned hospice agencies delivering quality care and not driving up Medicare spending needlessly? As with Medicare Advantage plans, we do not have good agency-specific information. The Private Equity Stakeholder Project report concludes, more generally: “Unfortunately, for-profit home healthcare and hospice companies have been linked to lower standards of care compared to their non-profit counterparts, including, but not limited to, a lower number of visits to patients by healthcare professionals (registered nurses, physicians, or nurse practitioners) in their final days in hospice, higher rates of hospitalization in home healthcare, and poorly paid—yet highly stressed—employees in both sectors.” “This is additionally troubling, because such for-profit entities serve higher percentages of people of color and those with low incomes.”

    Congress needs to start paying attention. Already a number of home health and hospice agencies have been charged with overbilling Medicare, underpaying their workers and neglecting patient care needs. For example, there are allegations that Kohlberg Kravis-owned BrightSpring, a home health care agency, put patients at risk, and other private-equity backed agencies have been charged with fraudulent billing of Medicare and Medicaid.

    In October of last year, Senator Elizabeth Warren reintroduced the Stop Wall Street Looting Act to stop private equity’s  “predatory” and “abusive” practices, but that bill is going nowhere at the moment.

    Here’s more from Just Care:

  • Medicare hospice benefit has become a luxury

    Medicare hospice benefit has become a luxury

    For many years, Medicare has covered palliative or non-curative care at the end of life through its hospice benefit. The benefit is intended to allow people, with six months or less to live to die peacefully in their homes rather than in an institution. But, as Alexis Drutchas et al. describe in Health Affairs, the Medicare hospice benefit has become a luxury because only a privileged few can arrange for all the requisite at-home care that Medicare does not pay for under the hospice benefit.

    A large portion of older adults and people with disabilities cannot afford to take advantage of the Medicare hospice benefit and are forced to die in hospital or in a nursing home. They do not have friends or family to care for them and they cannot afford to pay for the in-home caregiving they need in order to take advantage of the Medicare hospice benefit. Without family or friends to supplement the care that Medicare covers or the resources to pay for caregivers, Medicare hospice providers generally will not step in.

    Medicare pays hospice providers about $203 a day to provide limited routine care to people at the end of life. And, it caps spending on hospice care to $31,297 a person. For this money, people can only receive a small amount of care from nurses and home-health aides. Hospice providers do not want to take on patients who are at risk living on their own without caregivers at home.

    Talk to your doctor about your health care wishes at the end of life and, specifically, about the Medicare hospice benefit during your annual wellness visit, which Medicare covers. If you might be interested in hospice, find out whether there’s a hospice in your community that you would want to use. Keep in mind that one in five hospices suffer from severe deficiencies. 

    Be aware that for-profit hospice agencies might be very different from non-profit agencies. Two in three hospice agencies are now for-profit, owned by private equity and public companies. They might step in to provide hospice, such as addressing pain or helping with activities of daily living, but not to deliver the rich array of at-home benefits people need at the end of life. And, data on average hours agencies spend delivering care are not easily accessible.

    Hospice patients often get just 30 minutes of care each day or three and a half hours a week. Thirty minutes a day is not enough to assist people with even the simplest of needs, such as help taking medicines, going to the bathroom and bathing,

    Medicare is now spending an average of $80,000 on individuals in the last year of life. It spends whatever amount necessary for curative treatments and treatments for people with chronic conditions, even if there is no hope of a person’s survival. But, it limits spending for palliative care at home for people at the end of life.

    To serve the needs of people with disabilities and older adults, Medicare should not put tight constraints on what it spends for hospice care at home. And, it must insist on collecting data on the amount of time hospice agencies spend with patients and how, more broadly, these hospice agencies spend the money Medicare pays them.

    When choosing a hospice, people should know how many hours of care a particular agency provides from nurses and home health aides. Hospice Compare, the Medicare hospice comparison tool, does not provide this information.

    Here’s more from Just Care:

  • VSED, an end-of-life choice

    VSED, an end-of-life choice

    When it comes to health care, there seem to be fewer and fewer things that the US health care system gets right. End-of-life matters are no exception, with hospitals generally keeping people alive, even when they have asked to die, and forcing their loved ones to suffer through their slow passing. For this reason, Kevyn Burger reports for Next Avenue that more people are taking their deaths at the end of their lives into their own hands through voluntarily stopping eating and drinking or VSED.

    One way people help ensure a peaceful death is through electing hospice care.  Medicare covers hospice care, usually at home, for people believed to have six months or less to live. Hospice care focuses on easing pain and providing social and emotional supports for patients and their families, To learn more about the hospice benefit, click here.

    At the end of their lives, some people choose to speed up their death by forgoing food and drink, an age-old process. This choice is called “voluntary stopping eating and drinking” or VSED. People typically die in 10 days.

    Three quarters of Americans favor medical assistance in dying. Ten states–California, Colorado, Hawaii, Montana, Maine, New Jersey, New Mexico, Oregon, Vermont, and Washington—and Washington DC permit it. In these places, patients with six months or less to live can ask their doctors for medicines that allow them to die in their sleep. But, in other states, where this is not an option, VSED is an option.

    You need assistance with VSED to ensure your pain and other symptoms are well managed. Medicines should be available to you. It’s best for patients who are in very poor health to understand the process and be committed to it. Even with help from a doctor, it is not considered assisted suicide. But, a family member who helps with VSED should have written authority through a health care proxy document or durable medical power of attorney that he or she is carrying out the patient’s wishes if the patient cannot speak for himself or herself.

    A new book! “Voluntarily Stopping Eating and Drinking, A Compassionate, Widely-Available Option for Hastening Death” explains the process, including practical and ethical details.  It also provides case examples.

    On day one, patients can engage with their loved ones and say good goodbye. With no food or drink, they get weaker and are less able to engage. With no liquids, their organs fail. Quite quickly, they tend not to be hungry but they are thirsty. Water will extend life, so generally mists and swabs of the patient’s mouth are the treatment.

    With VSED, it’s common for patients to become delirious and agitated right before death. They are often given tranquilizers and anti-anxiety medicines.  Then, their heart stops, and they stop breathing.

    Here’s more from Just Care:

  • Paid caregiving should be valued as health care

    Paid caregiving should be valued as health care

    Lynn Hallarman, MD, former director of palliative care at Stony Brook University Hospital, writes for The New York Times about the value of paid caregiving. What’s most important for aging Americans is to have a caregiver who knows how to keep them safe and properly cared for. And, that should be valued as health care.

    Many children of aging parents cannot be there with their parents towards the end of their lives. Consequently, nearly half of people turning 65 today will need a paid caregiver to remain in their homes and communities, to live independently and with dignity. But, the cost is prohibitive for many. It can easily be $4,500 a month.

    Health insurance rarely covers caregiving services. Long-term care insurance tends to be extremely costly and usually only covers a portion of an individual’s home care. There’s also almost always a waiting period that can easily be three months or longer. So, insurance is generally not worth the investment.

    What’s as concerning is that paid caregivers tend not to earn a living wage; they also need better benefits and better training. We need more paid caregivers to provide direct care to older adults so that they can age in place.

    Today, states are left to bear a lot of the burden of providing home and community-based care to their Medicaid population. Hallarman believes a national partnership is needed. Funding for community-based services for older adults is critical.

    Older people in their last years of life tend to need a wide range of direct-care services. They might need help preparing meals, bathing, moving from one place to another, going to the toilet. It is hard and tiring work. It can also be extremely physically demanding.

    Medicare covers hospice services for people deemed to have less than six months to live, who opt for comfort care. Hospice services are generally not provided 24 hours a day. But, Medicare hospice covers care from a home health aide and others to ensure that patients are pain-free and living comfortably.

    A good caregiver is going to take note of increasing confusion in an older person, pain and whether and what the person is eating. The caregiver should be clipping toenails and checking for bedsores. We need to value caregivers for the extraordinarily challenging and important health care work they perform.

    Here’s more from Just Care:

  • Six reasons why you and your loved ones should create advance directives

    Six reasons why you and your loved ones should create advance directives

    Advance care planning is important for your peace of mind and for the people you love. You should begin care planning by creating an advance directive. An advance directive is a legal document that generally includes a living will and names a health care proxy. The living will states your wishes about your health care if you cannot speak for yourself and your health care proxy is someone you name to act on your behalf regarding your medical treatment if you are unable to speak for yourself.

    Here are six reasons why you and your loved ones should create advance directives, even if you’re in good health.

    1. An advance directive is free and easy to create. Advance directives need to be in writing, but creating one comes at no cost and is generally an easy process. Click here to learn what free resources are available and how to download a free advance directive.
    1. An advance directive helps you think about the goals you have for your health and health care. Making decisions about end-of-life care isn’t easy. Some people value prolonging of life over all else, where others prioritize relief of pain and suffering or the effects of one’s care on loved ones. Whatever you decide, planning ahead can help you consider these important issues and communicate them with your friends, family and healthcare providers in a time and place where you can think things through clearly.
    1. An advance directive helps you prepare for unexpected medical situations. Many people think that they do not need to plan for their care until they reach the later stages of life. However, end-of-life situations can happen to anyone. Creating an advance directive ensures you are prepared for any medical situation that may come your way.
    1. An advance directive comforts your family and loved ones. Caregiving is hard. It’s stressful to make an end-of-life decision for someone you love if you don’t know their wishes. And, it can cause friction within a family if people’s views are not aligned. Completing an advance directive and sharing it with the people you love helps bring your family together and provides comfort to them that they are following your wishes should they need to act on your behalf. An advance directive is a legal document that doctors and hospitals must honor. The advance directive ensures the people you love can make decisions on your behalf. 
    1. An advance directive allows your doctors and other care providers to better understand you and your desires. By creating an advance directive and sharing it with your doctors, you are telling them that you are informed and involved in decisions about your care. This can reinforce a meaningful relationship between you and your doctors that, in turn, can serve as an important source of emotional support during difficult times.
    1. An advance directive speaks for you when you cannot speak for yourself. Most importantly, an advance directive makes sure you are treated the way you wish to be treated, no matter what the circumstance. (Of course, if your treatment priorities change, you can change your advance directive.) Click here for a Jon Stewart interview of Dr. Atul Gawande about the value of  sharing your end-of-life priorities with the people you love repeatedly and over time.

    After you’ve created your advance directive, be sure to give a copy to your doctor as well as to the people you love. And, if you’re not ready to share it with the people you love, at least be sure they know where you keep it.

    To learn about Medicare coverage of hospice care, click here.

    [NB: This post was originally published on May 8, 2019.]

    Here’s more from Just Care:

  • Choose your hospice carefully

    Choose your hospice carefully

    The HHS Office of the Inspector General just issued two scathing reports on the Medicare hospice program. It found that nearly one in five hospice agencies suffered from serious deficiencies that put patient health and safety at risk. And more than four in five had at least one deficiency. Choose your hospice carefully.

    The Medicare hospice benefit can be extremely valuable to patients who choose palliative or comfort care rather than curative care at the end of life. Usually, care is provided in the person’s home. But, it can also be provided in an assisted living facility or skilled nursing facility. Some hospices have their own hospice inpatient unit.

    But, not all hospice care is the same. We do not know which specific hospice agencies the OIG found suffered from serious deficiencies or how many of the 1.5 million Medicare patients in hospice are endangered. The OIG examined only a small number of cases. It described a case in which a dying man’s feeding tube had maggots growing on it. And, it reported on a patient with Alzheimer’s going without appropriate wound care, which caused her to need her leg amputated.

    The Centers for Medicare and Medicaid Services (CMS), however, apparently does not have adequate authority to hold these companies to account when they cause harm to patients. CMS’ only available penalty is to end its contract with hospice agencies, which CMS has not chosen to do. Consequently, hospice agencies can cause harm to patients with apparent impunity. The OIG recommends that CMS have greater legal authority to penalize these hospice agencies.

    The OIG recommends Congress give CMS the authority to impose fines on hospice agencies, authority CMS already has for nursing facilities. That said, CMS does little to use that authority with nursing homes. And, why is CMS not simply terminating contracts with the facilities that put patients at risk because of their serious deficiencies?

    Moreover, why isn’t CMS flagging the agencies that have serious deficiencies on Hospice Compare, a government tool to help people choose a hospice agency. CMS has chosen not to publish state agency reports showing deficiencies because “they may be misleading.” CMS claims that state reports on hospice violations should not be available on Hospice Compare. As of now, survey reports from accrediting organizations, such as NCQA, the National Committee for Quality Assurance, cannot be publicly disclosed. But, that may change.

    CMS argues that Medicare-certified hospices are required to meet federal health and safety standards that keep patients safe. But, it clearly is not ensuring that they do. Before you choose a hospice agency, do your homework. Check with your state to learn about deficiencies the state has found with hospice agencies.

    Here’s more from Just Care: