Growth of for-profit hospices ripe for coverage
Given the recent spate – some good, some pretty muddy, and one I think pretty eye-opening – of articles about the growth of for-profit hospices, it’s probably worth taking a look at the issue, particularly for those of you who live in communities (such as the south and west) where the for-profits are most dominant. I think it’s also important to note some of the context that some of these articles omitted. And, yes, there’s a health reform angle. Several, in fact.
MedPAC started looking into the for-profits several years ago, as the sector started growing very rapidly. It became clear that the Medicare hospice “caps” and penalties meant to discourage too many long stays weren’t working. MedPAC has made a number of payment recommendations, including one that would revamp how all hospices are paid (which would make long stays less profitable) and another focusing more narrowly on creating a separate payment scale for hospice care in nursing homes.
MedPAC advises Congress but doesn’t set policy. And Congress has not acted on the recommendations to date – except that it did include in the 2010 health reform law a requirement that HHS review (and gives it a pathway to revamp) the hospice payment system in 2013. In addition, hospice faces about $7 billion of Medicare payment reductions over a decade under the Affordable Care Act. On top of that is the 2 percent Medicare provider cuts that will be “triggered” next year now that the supercommittee failed to agree on an alternative deficit-reduction steps.
All that being said, the recent Bloomberg piece by Peter Waldman on sales and marketing tactics by the for-profit chains was a hefty piece of reporting. It documents things like “Summer Sizzle” promotions, “Christmas Cash Blitz” and “Fall Frenzy” admission drives. The focus was pretty squarely on the business and sales practices. That is an important issue (and I haven’t seen it as well reported elsewhere ). But for those of you who may want to write about hospice, it’s not the only issue.
If you write about the growth of for-profit hospices – and some communities are now dominated by them – a few things to keep in mind.
- Don’t conflate quality and quantity. A flawed government payment system, and overly aggressive/inappropriate sales tactics (or even outright fraud) by some players isn’t always the same thing as a quality-of-care problem. A nursing home resident who ends up getting hospice care longer than he or she really should isn’t necessarily getting bad care – although they may well be getting care that Medicare shouldn’t be paying for.
- There’s a difference between large publicly-traded, investor-owned hospice chains and smaller, local for-profit hospices, which can be quite mission-driven (and low margin.) A hospice’s tax status doesn’t automatically define whether it provides good or bad patient care. (Remember the ongoing debate about which nonprofit hospitals are really “non” profit).
- Prognosis is really, really hard – particularly for the frail elderly nursing home population. It is hard to know whether a dementia patient is going to die within six months - even when there are some tell-tale danger signs of decline and deterioration. CMS did add some recertification and quality rules two or three years ago that are supposed refine the eligibility criteria - but they still aren’t a crystal ball.
- Long hospice stays may be a poor use of taxpayer/Medicare money but potentially so are very short stays. If people are only in hospice a couple of days, that often means that they got very aggressive care - which usually means very costly care until close to the end. That’s one thing if such care was what the patient/family chose. It’s another if the doctors never explained to the patient/family the likely prognosis, the likely outcome, the relative burdens and benefits of such care (and by “burdens” I don’t mean purely financial burdens). If Medicare paid for all that and then there is a mad dash for hospice to try to get pain and symptoms (physical and emotional) under control in the last few days, it’s neither good for Medicare’s bottom line nor does it give hospice the optimal circumstances for providing really good end-of-life care. Those last few days of life can be intensive for the hospice and a hospice with only very short-stay patients would be hard pressed to survive financially.
- How would small community and rural hospitals survive under some of the new payment models being discussed? Would they close? Get swallowed up by big chains? Both - i.e., first get swallowed up and then be closed because they aren’t as profitable?
- There have been several studies suggesting that patients who receive hospice care may live longer than similar terminally ill patients who do not. There was a whole spate of articles on this phenomenon back when Art Buchwald was dying – or rather when he was not dying. Most of the research I’m familiar with was on hospice care for specific cancers and heart diseases, not necessarily dementia, and not necessarily in the context of for profit hospice care for nursing home patients. But seriously ill people who get expert, interdisciplinary end-of-life care may bounce back, temporarily, and no longer fall in that six-month life expectancy category. If they really rebound, they should leave hospice care, as Buchwald did, with the right to resume it when the time comes.
- When asking whether there’s “too much” hospice care in nursing homes - don’t forget to ask what happens when there is not enough. This is the one area where I thought the Bloomberg story was incomplete – or even slightly misleading – by quoting a physician in Kansas as saying there should “never” be hospice in nursing homes. There is a lot of data – in peer-reviewed journals and medical conferences produced by academics and palliative care experts and nonprofits, not by the “industry” – that pain is poorly controlled in nursing homes, that there is overtreatment (feeding tubes being a prime example) of late-stage dementia patients in nursing homes, and that nursing home patients who could benefit from hospice/palliative care are instead sent repeatedly – often via costly ambulance-to the hospital. I met one doctor who called this care model “Our Lady of Perpetual Hospitalization.” This is a piece of the readmission issue that the health care reform law aims to address. There’s no room here to go into the convoluted mismatched incentives regarding nursing home care, but suffice it to say the revolving door won’t stop without quality end-of-life care in nursing homes – and nursing homes are often surprisingly ill-equipped to provide quality end of life care. Accountable Care Organizations, advanced medical homes, home and community based alternatives to institutional care, all part of health reform, may play a role here in coming years but it’s not going to be an overnight change.
- Hospice was not designed to be a substitute for, or side door to, Medicare-financed long-term care and it’s not the right way to pay for long-term care. Unfortunately, we don’t have a good way of paying for long-term care, nor for helping family caregivers.
- I’ve heard some rumblings – and it’s not a story I’m in a position to chase right now but may be worth looking into locally – that some groups or individuals are starting small nonprofits, specifically to flip them fast in sales to the big chains and make a lot of money. The Bloomberg piece reported on the recent uptick in acquisition of nonprofits.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. Finally, for now at least, remember that most hospice care takes place at home, with family members as caregivers. But not all terminally ill people have family members alive, or living nearby, or hale and hearty enough themselves to provide that care at home. For them, at least for some of them, the nursing home IS “home,” and that’s where they will access hospice.
Update: Just after I finished writing this blog post, Bloomberg and Kaiser Health News wrote about a big fraud case against a hospice chain based in Arkansas, and updated the status of other investigations.
- Bloomberg: AseraCare Hospice Accused by U.S. of Defrauding Medicare
- KHN: Lawsuit Accuses Company Of Fraudulently Cycling Patients Through Nursing Homes, Hospice Care
Reporter explores ‘dying peacefully in his sleep’
Filed under: Health journalism, Hot Health Headline
Spurred by the unenviable task of writing a very personal obituary to look beyond the stock phrases so common in those pieces, Virginian-Pilot reporter Elizabeth Simpson set out to find exactly what she was saying when she wrote that her 88-year-old father “died peacefully in his sleep.” She started with two simple questions.
What is it you die of when you don’t wake up in the morning?
And, is it the peaceful death everyone assumes?
She learned from a coroner that most common culprit for these deaths, including her father’s, is a cardiac arrhythmia, but that bit of knowledge raises more questions than it answers. She gained more insight from a post on AHCJ’s electronic discussion list (members can sign up for free!), where reporters shared both professional experiences and personal insights so compelling that Simpson included them in the story (you’ll find quotes about a third of the way down the page, under the “I posed the subject” subheading).
Simpson’s investigation takes her through the worlds of hard-nosed medical description, hospice and palliative care, life support and even sudden infant death syndrome, but ultimately ends up back where she started: “peacefully.”
Bush explained that sometimes you can die in your sleep during a massive stroke or a ruptured aneurysm. But in those cases, a person usually will have complained earlier about symptoms like a headache or other pain. A heart attack or pulmonary embolism usually will cause enough pain to lead the person to wake and go to an emergency room.
But death during sleep with no symptoms at all is likely due to the heartbeat going haywire. In Bush’s opinion, it is the way to go.
Peaceful? She thinks so.
Sometimes, she said, such a person will be curled up in a sleeping position, the blankets tucked around them, no evidence of thrashing about. Their faces are serene, their eyes closed. By contrast, in cases where death comes while not sleeping, there’s a 50-50 chance the eyes will be open.
Where you are determines your end-of-life care
As you’ve likely noticed, the Dartmouth Atlas team has now focused its lens on end-of-life care and found, not surprisingly, what amounts to “more of the same.” Kaiser Health News’ Jordan Rau has the nuts and bolts, while Joanne Kenen, writing for Miller-McCune Magazine, takes a long view on the story, putting it into the context of popular Dartmouth Atlas pieces (think McAllen, Texas) and end-of-life outliers (La Crosse, Wis.). While you’ll have to check out her story for the in-depth version, here’s Kenen’s summary of the report:
Overall 1 in 3 of these patients died in the hospital, sometimes in the ICU and sometimes on life support, but there was significant variation from one region or even one hospital to another. Six percent of the patients received chemotherapy in the last two weeks of life, but in some regions and academic medical centers the rate went above 10 percent. Half got hospice but often for just a few days, too little for them and their families to fully benefit from the medical and psychosocial assistance and comfort hospice can offer.
If you’re looking for caveats, be sure to hit the second half of Rau’s story.
How the system rewards end-of-life intervention
Caitlan Carroll of American Public Media’s Marketplace tries to explain why, even though “80 percent of patients say they don’t want to be hospitalized or given intensive care during the last phase of their lives,” so many people get intensive medical intervention at the end anyway.
In the end, Carroll finds that family and friends don’t want to lose a loved one, doctors don’t want to lose a patient, and doctors aren’t compensated for hospice and palliative care the same way they are for aggressive intervention.
Carroll’s report is the first installment of a two-part series funded by a California Endowment Health Journalism Fellowship.
Drug data could inform stories about elder care
The 2007 National Home and Hospice Care Survey (NHHCS ) Medication Public-Use File and Documentation are now available for downloading.
One group of researchers used earlier NHHCS data to “examine changes in hospice services over time, as they were collected during the period from 1992 to 2000, paralleling the period of substantial growth in hospice use and spending.”
With recent studies and news about the increase in use of antipsychotics in the elderly, this data might be useful in reporting such stories and documenting the increase, as well as stories about how treatments have changed.
The 2007 NHHCS Medication Public-Use Data File is supported by SAS, SPSS, and STATA input statements. The documentation includes three PDF files: technical notes, a data dictionary, and a PDF file that provides drug name codes, drug estimates and rates, and drug characteristics.
Kleyman: Reform scare tactics hurt ethnic elders
Filed under: Health care reform, Health policy, Hot Health Headline
Paul Kleyman of New America Media about a cruel twist: the “death panels” label propagated by some extremists may serve to scare away the people who would benefit most from the end-of-life care the much-maligned provisions are designed to organize. Kleyman writes that “fear mongering” in the health care debate will hit ethnic elders with particular force because “apprehensive about past racism in the health care system, many elders of color may be further deterred from taking advantage of opportunities to plan ahead and optimize their ability to leave this life with a sense of dignity and control.”
Older African Americans and Latinos are also more likely than whites to find themselves in ICUs during the last six months of their lives, a disparity that Kleyman says shows just how much elders in those communities need end-of-life planning assistance.
New America Media is a collaboration between and advocacy group for more than 2,000 ethnic media outlets in the United States.
Story documents end of life for woman and family
In “The Final Journey” in Cure magazine, contributing photographer Beatriz Terrazas and Cure editor-at-large Kathy LaTour document the final six months of 64-year-old Judy Abernathy’s life.
Abernathy invited CURE to join her family as they began moving toward the end of her life from metastatic lung cancer.
They follow Abernathy’s visits to a palliative care physician, report on her decision to stop a clinical trial so she could continue to be part of her family, describe the effect her illness has had on the family and document the steps she takes in hospice care.
“I have tried to stay on top of everything because when you go to sleep you don’t know if you are going to wake up,” Judy says lightly. It’s clear she is trying to begin the final discussions she wants to have with her children.
The Web site includes a eulogy written by Abernathy’s granddaughter - a journalism student - and features about hospice and palliative care and an article about controlling pain in cancer patients.
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